Inspection on 14/08/07 for Glengarry Road, 72

This inspection was carried out on 14th August 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glengarry Road, 72 20/06/06

Glengarry Road, 72 30/09/05

Glengarry Road, 72 24/08/05

Glengarry Road, 72 03/02/05

Glengarry Road, 72 29/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Glengarry Road, 72 London SE22 8QD Lead Inspector Lynne Field Unannounced Inspection 14th August 2007 10:00 DS0000007101.V342546.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 DS0000007101.V342546.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. DS0000007101.V342546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glengarry Road, 72 Address London SE22 8QD 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 8693 6743 0208 693 6743 glengarrystaff@southsidepartnership.org.uk www.southsidepartnership.org.uk Southside Partnership Mrs Abimbola Adewunmi Ogunbadejo Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) DS0000007101.V342546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 People male or female with mental disorder other than dementia some of whom may be over 65 years old. 20th June 2006 Date of last inspection Brief Description of the Service: 72 Glengarry Road is a care home providing personal care and accommodation for 6 people with mental health needs, some of whom are over the age of 65. There are currently two men and four women living at the home. Southside Partnership, a voluntary organisation, manages the service and Hexagon Housing Association owns the building. The home is in Dulwich, South London, close to shops, pubs, the post office and other amenities. The home is a threestorey building. Bedrooms are all single, and on the first and second floors. There is no passenger lift and the building is not wheelchair accessible. There is a small garden to the rear. The fees for a place at the home are £318:57 per week. DS0000007101.V342546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in August 2007. The registered manager was on annual leave so the deputy manager facilitated the inspection. The inspector was given a tour of the building and met three residents during the course of the inspection. Records and documents were checked. The residents the inspector met said they were very happy to live at the home and were well looked after. During the inspection staff interaction with residents was observed to be very regular and conducted in a respectful manner. The inspector looked at all the information received about the service as well as the on site inspection and found that the home continues to provide a very high standard of care to the people who live there. What the service does well: What has improved since the last inspection? The home has commissioned an occupational assessment of the entire building regarding individual residents in the home to ensure they have all the specialist equipment and adaptations they need to use the facilities in the DS0000007101.V342546.R01.S.doc Version 5.2 Page 6 home safely. Individual residents have been referred and assessed by the physiotherapist and the recommendations have been actioned. The home has continued to have an open day programme. This gives families and friends of residents the opportunity to visit the home and to ask any questions. Medication is now in monitored dosage packs. Residents and staff went through the in house training on death and bereavement of residents. 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 be made available in other formats on request. DS0000007101.V342546.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 DS0000007101.V342546.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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs and aspirations are assessed, so that a service tailored to their needs could be provided. EVIDENCE: The inspector was shown the statement of purpose and the resident’s guide, which includes the complaints procedure in the resident’s guide. The deputy manager told the inspector, that these are regularly checked and updated to reflect the changes in the home and the organisation that runs the service. A resident had recently been admitted to the home. The inspector was told that when a vacancy arose, the home would follow their procedures outlined in the statement of purpose and service users’ guide. The deputy manager said the prospective resident was invited to visit the home with family members or friends to help them decide if the home could meet their needs. The registered manager and the deputy manager followed this up by going to assess the resident and completing a full needs assessment and risk assessment to ensure the home could meet the prospective residents needs before a place in the home was offered. Copies of the assessments, risk assessments and the care management assessment were seen on file. The resident was informed of DS0000007101.V342546.R01.S.doc Version 5.2 Page 9 the terms and conditions of their accommodation and tenancy agreements as well as the fees they would be charged, what they cover and any additional costs. Copies of the house rules and written contract were signed by the resident and the registered manager. DS0000007101.V342546.R01.S.doc Version 5.2 Page 10 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): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are consulted and supported to make decisions about their lives by staff and appropriate independent professionals. Potential risks are identified and residents are supported to take risks within a risk management framework. EVIDENCE: The inspector viewed three residents’ files. The home encourages residents make decisions for themselves by involving them in the development of the care plans through staff support. Care plans viewed by the inspector give a description of residents’ individual behaviours, reactions and preferences and how the resident likes to be treated. The inspector saw copies of risk assessments that have been carried out. Care plans and risk assessments are reviewed with residents where possible every DS0000007101.V342546.R01.S.doc Version 5.2 Page 11 six months or sooner if necessary. Details of any changes to the risks are recorded in the care plans along with details of how to manage the risk. The home has internal reviews. The inspector was told they had held two monthly reviews for the new resident to make sure they were settling in and to review and amend the care plan if necessary. The inspector was told one resident does not like any documents and will rip up any paper work with their name on it. The service works around this by not putting their name on any documents they are given. Copies of records of key work sessions with individuals were on resident’s files were seen on the files the inspector viewed. Reviews take place once or twice a year depending on need and there is a twice-yearly meeting with all staff and service users present to evaluate how the home is meeting its aims and objectives. DS0000007101.V342546.R01.S.doc Version 5.2 Page 12 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): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents engage in appropriate, enjoyable and fulfilling activities and mix with the general community. Residents are actively encouraged to keep in touch with friends and family and develop appropriate friendships. Residents’ rights and responsibilities are respected. EVIDENCE: The inspector met two residents during the course of the inspection and one just before leaving as they came home from being out for the day. Residents said “staff listened to them and that was important” and “feels staff help him”. Another said “I am satisfied with everything and feels he is able to approach any member of staff when he needs assistance”. DS0000007101.V342546.R01.S.doc Version 5.2 Page 13 One resident has an agreement to go to the day centre that they have signed. Decisions about what activities residents were going to take part in were made in a variety of settings. Some decisions were made at residents meetings, others were made at reviews and others individually in key worker meetings. Residents meeting are held once a month at the weekend to enable all the residents to attend. The residents discuss the menu, trips out and any concerns can be raised. Each resident has a chore to do on each day of the week. They discuss what chores need to be done and agree who will do them. If the residents have any personal concerns these would be discussed at key worker meetings. The inspector saw records of key worker meetings that were signed by the resident and the key worker. The inspector was told all the residents are expected to do their own laundry and are supported to this. One resident has a cat that she looks after and has complete responsibility for. Two residents are encouraged to collect their money from the post office with the support from staff and four are able to go themselves to collect their money. The home encourages residents to keep in touch with their families and families are involved in the home. They are invited to reviews and kept informed on day-to-day basis. The inspector was told the home held an open day for family and friends to come to the home and find out how things work and meet all the staff and residents. One resident told the inspector they go to see their sister and another resident’s family come to visit them. There were records of these visits on the resident’s files. DS0000007101.V342546.R01.S.doc Version 5.2 Page 14 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): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support, in the way they prefer and their physical and emotional needs are met. Residents are protected by the homes policies and procedures for dealing with medicines. Medication administration was found to be properly documented and is handled safely. EVIDENCE: The inspector checked three residents’ files. The inspector was told two residents need help with personal care and other four residents only need support through prompting to look after themselves. Care plans contain information about how residents like to be supported in all aspects of their daily lives. As part of the residents daily living development plan, each resident is encouraged to take part in the running of the home and has household chores that they do on a regular basis. As well as care plans residents have life DS0000007101.V342546.R01.S.doc Version 5.2 Page 15 plans. The inspector noted that these need to be developed to include more information about the resident and an “End of Life Plan” where appropriate. Resident’s medication is stored securely in a locked medication cabinet in the staff office. The inspector inspected two residents medication at random with member of staff. All medication stocks checked where in order. Any allergies the residents may have are highlighted and recorded on their medication charts. The inspector was told the registered manager audits the medication weekly and this was recorded on the residents’ medication chart. It would be good practice to introduce a running total system that is carried forward from month to month for PRN medication. Staff induction includes medication training and medication administration records. Then there is further training while working in the home. There was a copy of all staff signatures that dispense medication and information about the medications in use. DS0000007101.V342546.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are safeguards in place to protect the resident from abuse, neglect and self-harm. EVIDENCE: There is a complaints policy and the inspector saw the complaints book. No complaints have been recorded since the last inspection. Residents are able to raise any day-to-day issues in their monthly meeting and the minutes show that action is taken in response to any issues raised and followed up at the next meeting. The inspector was shown a copy of the home’s Adult Protection and Whistle Blowing policy, which conforms to Local Authority requirements. All staff have received vulnerable adults training. The organisation now refers staff to POVA as appropriate. None of the staff in the home have been referred for inclusion on the POVA list. The home has a policy regarding the protection of the resident’s finances. As part of the inspection the residents’ money and petty cash accounts were inspected and they were in order. A receipt must be obtained for all purchases and the amount spent recorded in the residents’ accounts book. The member of staff supporting the resident when the money is spent signs this. Personal money and valuables are checked twice daily as part of the handover system. DS0000007101.V342546.R01.S.doc Version 5.2 Page 17 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): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable with adequate private and shared space, toilets and bathrooms. Residents’ bedrooms promote their independence. The home is well maintained and furnished. EVIDENCE: The home is clean, comfortable and homely with no unpleasant odours. There is a separate lounge and dining room and six single bedrooms. Residents choose their own furnishings and fittings for their rooms and this reflect their needs and indviduality as well as promoting their independence. All residents bedrooms are lockable. The staff can use a master key if this is recorded in the residents risk assessment and in the event of emergencies. There are three bathrooms and toilets that provide sufficient privacy and have appropriate fittings/equipment to ensure the residents safety. DS0000007101.V342546.R01.S.doc Version 5.2 Page 18 Residents have specialist equipment as required to maximise their independence such as safety rails on the stairs, armchair raiser/extension. Communual and shared spaces complement and supplement residents individual rooms. Shared spaces are comfortable, safe and fully accessible for shared activities and for private use. The inspector was given a tour of the building and noted the fire door to the laundry was being wedged open. If this door is to be kept open, it must be fitted with a fire door guard. See Standard 42. There was a preivous requirement that the registered person must ensure that an occupational therapists assessment of the entire building takes place to make sure that the individual residents at this home have all the specialist equipment and adaptations they need to safely use the facilities and building and that issues such as the stairs in the building are evaluated. The inspector spoke to the registered manager after the inspection, who said the health and safety office had come to do a mobility assessment of all the residents and recommendations made in that report had been met as a priority. One resident had been refered to the physiotherepist and they had made a recommendation about their chair and this had been addressed. DS0000007101.V342546.R01.S.doc Version 5.2 Page 19 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): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriately trained staff meets the residents’ individual needs. The recruitment procedures followed are safe, thorough and comply with legal requirements. Formal supervision is not happening for all staff on a regular basis. EVIDENCE: The training records were seen by the inspector and showed that the rolling programme of training for staff covers all the core areas of statutory training and additional training that is focussed on the particular needs of this service user group. Staff confirmed they had been on medication refresher training and had gone through LADAF induction training when they started to work for the organisation. Staff who spoke to the inspector said the “training was excellent “. All care staff hold NVQ Level 3 in health and social care. DS0000007101.V342546.R01.S.doc Version 5.2 Page 20 The inspector visited the organisation’s head office where the staff files were kept, prior to this inspection and was able to inspect relevant documents relating to the selection and recruitment of staff. The organisation has an induction checklist for support staff that the managers must follow to ensure all staff have the same induction standard. The inspector inspected all staff CRBS checks that were available. The human resources manager told the inspector they followed the CRB guidance and destroyed all CRB’s after six months but before CSCI has seen them. The guidance states that providers should retain the CRB’s for 6 months or until seen by CSCI (if that is longer). The organisation needs to follow the guidance on how long CRB’s need to be kept. The inspector was told the organisation is planning to keep copies of certain documents relating to staff in a locked cabinet in the home they are based at. They have written to all staff asking for written permission do this. Most staff have agreed but this will not be done until all staff have agreed. Staff are only appointed after CRB’s are in place and two references have been received from their previous employer. Even when staff transfer with in the organisation, references are still taken up. New staff are given a job description, a contract and must have medical checks. All staff are given a copy of the staff handbook, which was reviewed in April 2006. The inspector checked supervision records and matrix and found supervision of some staff had been very spasmodic. This needs to be reinstated. The inspector was told regular bank workers receive supervision every six months. Staff have regular staff meetings every month. The inspector saw copies of the minutes that are recorded and actioned. DS0000007101.V342546.R01.S.doc Version 5.2 Page 21 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): 37,38,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a home that is well run and managed. The registered manager is qualified and experienced and runs the home well. The health, safety and welfare of residents is promoted and protected. EVIDENCE: The registered manager who has completed both the Registered Managers Award and the Care NVQ Level 4 qualifications was on annual leave on the day of the inspection. The inspector was told she has been the manager of this service for around six years and has around ten years experience in this field. DS0000007101.V342546.R01.S.doc Version 5.2 Page 22 The inspector found the home well run in her absence and the inspection was well facilitated by the deputy manager and the staff on duty that day. The home has a business plan that states how the home aims to improve over the next year. The inspector was told the whole staff team have an input into the business plan, which incorporates the team plan. In this there are team objectives, an action plan and a record of the progress. The home continues to operate a system of quality assurance where residents are involved. The records show that this is progressing with action plans being developed every year to improve service delivery. Residents are encouraged and are involved in the recruitment and selection process and the induction of new staff. Records indicated that all fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. The laundry door must be fitted with a fire door guard. See standard 24. DS0000007101.V342546.R01.S.doc Version 5.2 Page 23 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 3 3 3 4 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 X X 2 X DS0000007101.V342546.R01.S.doc Version 5.2 Page 24 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. 2. Standard YA36 YA42 Regulation 18(2) 23(4) Requirement The registered person must ensure that staff working at the home are supervised regularly. The registered person must take adequate precautions to protect the home from fire by having the laundry room fitted with a fire door guard. Timescale for action 30/10/07 30/11/07 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 YA20 Good Practice Recommendations It would be good practice to introduce a running total system that is carried forward from month to month for PRN medication. DS0000007101.V342546.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 DS0000007101.V342546.R01.S.doc Version 5.2 Page 26 - 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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