Inspection on 09/02/06 for Glengall Road [83]

This inspection was carried out on 9th February 2006.

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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glengall Road [83] 04/05/07

Glengall Road [83] 02/08/05

Glengall Road [83] 21/01/05

Glengall Road [83] 21/07/04

Glengall Road [83] 17/02/04

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Edenvale

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Chatsworth Care - Dawson House

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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 Glengall Road [83] 83 Glengall Road Woodford Green Essex IG8 ODP Lead Inspector Jackie Date Unannounced Inspection 9th February 2006 10:00 Glengall Road [83] DS0000025954.V281181.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 Glengall Road [83] DS0000025954.V281181.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. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glengall Road [83] Address 83 Glengall Road Woodford Green Essex IG8 ODP 0208 559 0797 0208 506 1744 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) Redbridge Community Housing Limited [RCHL] Mrs Catherine Bernadette Copestake Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: Glengall Road is a care home for adults with learning disabilities. It is one of a number of homes run by RCHL, a not-for-profit organisation. The home is registered for 10 people but as the double rooms are no longer being used for two people they will be changing this to seven. The residents have profound learning disabilities, additional physical disabilities and little or no verbal communication skills. They have limited ability to make decisions about their lives. Glengall Road is a large detached house in Woodford Green close to shops and public transport. There is an annex in the garden and the laundry, storage facilities and a disused spa are in this. There is a small garden with a raised fishpond. Some of the residents go to day services and activities are organised by the staff. There is an adapted minibus that is used for activities and trips. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for about three hours and took place during the morning and early afternoon. It was the second of the two inspections that each home must have during the inspection year. During the two visits all of the key standards have been checked. The manager, staff and residents were spoken to. All of the communal rooms in the house were seen and care and other records were checked. The main purpose of this visit was to monitor the progress of the requirements from the previous inspection. Feedback forms were left for staff to give their comments on the service. What the service does well: What has improved since the last inspection? What they could do better: There are three requirements from this inspection that are related to recruitment and staff records both of which are dealt with by the head office. The organisation has been addressing these requirements and they will be checked by a further visit to the head office. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 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 Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Residents and their representatives now have a written and costed contract/statement of terms and conditions and will therefore be clear about what they are entitled to. EVIDENCE: The residents have a contract between themselves and the Housing Association/provider. Previous inspections have required that the organisation must provide a fully costed contract/statement of terms and conditions to each resident. These have now been developed and include information about individual financial arrangements. The contracts were available at the home but none of the residents are able to sign these. Therefore relatives will be asked to sign on behalf of the residents. This means that there will be clear information available about the service that will be provided to individual residents. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs. EVIDENCE: All of the residents have a support plan and these contain information about how each person likes and needs to be supported. For example “likes music and discos, outings”. “Dislikes it when her radio is broken”. Assessments of need have also been carried out. The key worker reviews the support plans every month. Relatives and social workers are invited to six monthly reviews. The care plans seen had all been updated when needed. The degree to which residents can be involved in the development of the plan is very limited due to their profound learning and communication difficulties. Information about residents’ needs is comprehensive and is up to date and therefore gives staff the information that they need to support each individual and to meet their needs. This meets the requirement from the previous inspection Each resident has a daily log that is completed by the staff. At the time of the last inspection the information in these logs tended to be about feeding, toileting and personal care. The daily recordings have improved but this is an Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 10 area for ongoing development to ensure that information is recorded about all aspects of each persons day. There are risk assessments in place. These identify risks for the residents and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. Risk assessments are also being reviewed regularly to ensure that they are up-to-date. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 17 The residents are supported to take part in activities and to be part of the local community. Residents are given meals that they like and that meet their needs and individual preferences. EVIDENCE: The residents all have profound disabilities and very high support needs. They are extremely dependent on staff. Some of the residents attend local day centres and others are supported to access activities by the staff team. For example arts, music, videos and manicures in the home. A pianist visits two weekly to play for the residents. An aroma therapist visits weekly and three of the residents enjoy having aromatherapy. Staff are also exploring the possibility of using an outreach service to support residents to do activities. They also hope that they will be able to arrange the funding to develop the outbuilding into a sensory room. Residents support plans include information about what they like and dislike doing. For example “ likes travelling and swimming”. “Dislikes eating out, especially in a crowded environment”. On Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 12 the day of the inspection three of the residents went to a pottery group supported by staff. Two of the residents had a four-day break in Bognor last year and others had daytrips. One of the residents is going to a show in Southend and staying overnight at a hotel. This has been arranged in conjunction with another of the organisations nearby residential homes. The manager and staff continue to try to increase the number of activities that residents can participate in both in the home and in the community. Menus are based on the staffs knowledge of residents’ likes, dislikes and needs. The food offered is nutritious and varied. A cook is employed for five days per week and the main meal is usually at lunchtime. Two residents are on low-fat diets and one has their food blended. Residents’ support plans contain details about what they like and dislike eating. For example one residents’ plan stated that she does not like eggs, and another’s said that she likes sweets. One of the residents has become very confused and its been difficult to get her to eat. Her care plan clearly says that she may want to eat her pudding first and that this is her choice. Therefore residents do get meals that they like and that meet their needs. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents receive personal care that meets their individual needs and preferences. The staff team support the residents to get the healthcare that they need. Medication is appropriately administered by the staff. EVIDENCE: The residents all require a lot of support with their personal care and details of the help that they need and how they prefer to be supported are in their support plans. All of the residents are registered with a local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of health care issues and show that residents have regular access to health care professionals. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and when needed the chiropodist. The staff team had concerns about the health care needs of one of the residents and a review was arranged. Assessments were carried out and another placement was found for her in a home that provided nursing care. As previously stated one of the Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 14 residents has become confused and it has been difficult to encourage her to eat. However the staff team have continued to support and encourage her and as a result of this she has gained a little weight. The staff team monitor the residents’ health and make sure that any required checks are carried out and followed up and that residents’ health needs are addressed. None of the residents can self medicate and the shift leader administers medication. Medication is appropriately and safely stored in a locked cabinet and medication administration records are kept. Four of the staff team are due to receive medication training from Boots. The previous inspection made two requirements with regard to medication. The first was that protocols/guidelines must be in place for the administration of “as required” medication. The second was that the medication policy/procedure must be amended to include the action to be taken in the event of an error in the administration of medication and also the procedure for when medication is taken out of the home. Both of these are now in place. Therefore the residents safely receive medication that is prescribed for them. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 15 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): The 22 & 23 There is a complaints procedure that would be followed in the event of any complaints being made. The systems for managing residents’ finances ensure that they are protected from financial abuse. EVIDENCE: There is a complaints procedure and this is displayed in the home. However due to the degree of their disability it is unlikely that any of the residents would be able to make a complaint without support. There have not been any complaints since the previous inspection. The organisation has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. All of the residents need help with their finances and do not have the capacity to understand about the concept of spending or saving money. Records are kept of financial transactions. Some residents’ financial affairs are managed by their families. The head office manages others. A random sample of residents’ monies were checked as part of this inspection and were correct. The manager carries out spot checks on residents’ monies and checks are also carried out as part of the monthly responsible persons visits. In addition an annual financial audit is also carried out. Therefore systems are in place to ensure that residents’ monies are appropriately managed and to protect them from financial abuse. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 16 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, 27, 28, 29 & 30 The residents live in a clean and comfortable home that has suitable aids and adaptations for their needs. EVIDENCE: Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 17 The home is a large detached two-storey house near to the local shops and bus routes. There is a lift to the first floor and the second floor is just used for storage. There is a lounge, dining room, three bedrooms, a bathroom and kitchen on the ground floor. The office, four bedrooms and a shower room are on the first floor. All of the residents now have single rooms. The laundry facilities are situated in an annex in the garden. The lounge does need to be redecorated but the lift is about to be refurbished and this work will affect the lounge. Therefore when this work is complete the lounge will be redecorated. There are enough baths, showers and toilets and these are adapted to meet the residents’ needs. Last year a ceiling hoist was fitted in the ground floor bathroom and a first-floor bathroom was refurbished and a walk-in shower fitted. In addition new hoists and slings were purchased for residents that need these. Therefore the equipment needed to meet the residents’ specialist needs is available in the home. At the time of the inspection the home was clean and free from offensive odours. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 18 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): 34 The organisation has taken action to address concerns about the robustness of recruitment practice and this will be tested via a further inspection of recruitment files at the organisations head office EVIDENCE: During last year an inspection of a sample of personnel files at the organisations head office showed that not all of the required checks on staff could be demonstrated to have taken place. This was discussed with the organisation and the Commission received an action plan of how this was going to be addressed. A further visit to head office will take place to confirm that all of the necessary action has been taken and that the recruitment procedure is robust. The requirements with regard to recruitment will remain until this visit has taken place. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 19 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): 41 & 42 The home provides a safe environment for the residents. The organisation has taken action to address concerns about staff records and this will be tested via a further inspection of recruitment files at the organisations head office. EVIDENCE: During last year an inspection of a sample of personnel files at the organisations head office showed that not all of the required staff records were maintained. This was discussed with the organisation and the Commission received an action plan of how this was going to be addressed. A further visit to head office will take place to confirm that all of the necessary action has been taken and that the necessary records are kept. The requirements with regard to records will remain until this visit has taken place. All of the necessary health and safety checks are carried out and a safe environment is provided for the residents. Hot water temperatures are Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 20 checked weekly to ensure that they do not exceed the prescribed 43°C. The bath and shower are now included in the weekly checks as required by the previous inspection. Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 21 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 X 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X X X 2 3 X Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 22 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 YA34 Regulation 19 Requirement The registered persons are required to ensure that their recruitment procedure is robust and in line with regulation. The registered persons are required to maintain records for the protection of service users in line with Schedule 2 of the Care Homes Regulations 2001. For new staff before appointment. The registered persons are required to maintain records for the protection of service users in line with Schedule 2 of the Care Homes Regulations 2001. For existing staff. Timescale for action 31/03/06 2. YA41 17 31/03/06 3. YA42 17 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Glengall Road [83] DS0000025954.V281181.R01.S.doc Version 5.1 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. 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