Inspection on 07/01/06 for Fenwick Road, 29

This inspection was carried out on 7th January 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 6 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 01/11/06

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 7th February 2006 13:30 Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 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.V280308.R01.S.doc Version 5.1 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.V280308.R01.S.doc Version 5.1 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 0207 732 5261 fenwick@saffrenland.co.uk Saffronland Homes Mariam Moshood Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th June 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. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the afternoon of 7th February 2006. The manager and deputy manager were on duty and both facilitated the inspection. There was one service user in the home, with her father visiting, and the inspector was able to speak to them. 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. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 6 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.V280308.R01.S.doc Version 5.1 Page 7 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): 1,2,4. A new service user did not have the security of knowing her needs had been assessed before admission. However she and her family have benefited from a settling-in period. There is good information available on the home although the format is inappropriate for this service user group. EVIDENCE: The home has an up-to-date Statement of Purpose and Service user guide which still need to be put into a format which will be accessible for service users. The manager said that she has started on this process. A new service user had been admitted recently. She did not have an up-to-date multidisciplinary assessment before admission and the assessment done by the home was not full enough to make up for this. The service user was not able to visit the home before admission although the manager was clear that this would normally happen, and her father was able to visit on her behalf. The first three months have been used as a trial period with a review date booked. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 8 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): 7,10. The home works to ensure that service users can make as many decisions about their lives as possible. Confidentiality issues are handled appropriately. EVIDENCE: The manager was clear about the need for service users to make as many decisions as possible and described how this happens both in day to day life and in planning activities. She also ensures that service users and their families are put in contact with a local advocacy scheme. The home has a confidentiality policy and the manager trains new staff to this as part of induction. The policy could usefully be updated to include information on the data protection act. Files are kept securely. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 9 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): 13,14, 15,16,17 Activities especially at evenings and weekends are low and service users have not been having an annual holiday. Service users rights are respected and they are well supported in maintaining relationships. Food provision is good. EVIDENCE: At the last inspection it was seen that service users’ did not have a varied activities programme outside the home. Some extra provision has been made but there is still a need for more activities for service users outside the home. The manager confirmed that staff hours do not always allow for this. Up until now service users have not had an annual holiday. The manager is planning one for this year and this should be part of the basic contract price. Service users are supported to maintain and enhance links with family and friends and to develop personal relationships. They have the choice of when they take part in activities and who they meet with. Where possible they have keys to their rooms and the front door. At the last inspection it was seen that the menu was not very well balanced nutritionally. On this visit the menus seen were well balanced, nutritionally and in terms of ethnicity. Fresh produce is used and seemed to promise tasty meals. There were picture cards to show service users what they would be getting. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 10 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): At the last inspection it was found that the home looked after the personal and health care needs of its service users well. Although not inspected at this visit, observations demonstrated that this continues. EVIDENCE: Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 11 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 There is a complaints policy is not in an accessible format for this service user group. EVIDENCE: The investigation of complaints was seen to be good at the last inspection. The complaints policy did not include details of the CSCI but has now been updated to include these. The policy also needs to be in a format accessible for service users. The manager said that this process has been started. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 12 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): 24,26,27,29,30 Service users have a comfortable, clean home which is well adapted to their needs. EVIDENCE: At the last inspection it was found that service users have a comfortable home with all facilities needed. Adaptations needed to maximise independence are assessed for and provided. The environment has been enhanced since the last visit, by repairs to the exterior and re-decoration of the interior. All parts of the home, including the bathrooms are bright and well decorated. The home is also well maintained and was clean and hygienic except for the walls of the laundry which need to be of a washable material. Service users rooms also need two comfortable chairs of a proper quality. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 13 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): 32,33,35 Service users receive good support from experienced and trained staff. EVIDENCE: The last inspection found a well supported staff group who are able to give consistent care to service users and this continues. This continues to be true and has been enhanced by an appointment to the deputy manager post. Arrangements are also now in place to have the appropriate number of staff trained to NVQ 2 standard and a good system was seen that shown that staff individual training needs are assessed as part of the home’s training plan Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 14 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, 39,42 A competent manager ensures the health and safety of staff and service users. Quality assurance systems need to be formalised and enhanced. EVIDENCE: The manager has experience both in management, and with this service user group. She demonstrated in conversation that she is competent to run the home and this was borne out by observation of the running of the home. She is currently undertaking NVQ 4 with care and hopes to be finished by June of this year. The manager described some methods of monitoring quality in the home. These were through monthly visits by the person in control and some questionnaires sent out to relatives and other agencies. These questionnaires need to be rather more detailed, be analysed and annual report written on the findings. The home also has an informal annual development cycle which needs to be formalised and recorded. All health and safety systems inspected were in order. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 15 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 2 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 x ENVIRONMENT Standard No Score 24 3 25 x 26 2 27 3 28 x 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x 3 x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x 3 x 2 x x x 3 Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 16 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 YA2 Timescale for action 14(a)(b)(c)(d) The registered person must 30/04/06 ensure that new service users are only admitted on the basis of a full assessment of their needs, and written confirmation that the home is able to meet those needs. 30/06/06 16(2)(m)(n) 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 of 30th September 2005 not met 16(2)(n) The registered person must 30/06/06 ensure that a seven day annual holiday is included in the basic contract price. 22 The registered person must 30/06/06 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 policy is now complete but has not yet been put into a format accessible for service users. Target DS0000007096.V280308.R01.S.doc Version 5.1 Page 17 Regulation Requirement 2. YA13 3. Ya14 4. YA22 Fenwick Road, 29 5. YA26 16(2)(c) 6. YA30 13(3) 7 YA39 24 date was 30th September 2005 The registered person must 30/04/06 ensure that service users rooms have two comfortable chairs of good quality. 30/06/06 The registered person must ensure that the laundry walls are made of washable material. Target date of 31st December 2005 not met. The registered person must 30/08/06 ensure that there is an effective quality monitoring system and annual development plan. 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 10 Refer to Standard YA1 YA4 YA10 Good Practice Recommendations It is recommended that the statement of purpose and service users guide is in a format accessible to this service user group It is recommended that the manager continue to make every effort to ensure that service users visit the home before admission. It is recommended that the home’s confidentiality policy should be updated. Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark 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 Fenwick Road, 29 DS0000007096.V280308.R01.S.doc Version 5.1 Page 19 - 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. 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