Inspection on 20/06/06 for Glengarry Road, 72

This inspection was carried out on 20th June 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glengarry Road, 72 14/08/07

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 Lisa Wilde Unannounced Inspection 20th June 2006 11:00 Glengarry Road, 72 DS0000007101.V300213.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 Glengarry Road, 72 DS0000007101.V300213.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. Glengarry Road, 72 DS0000007101.V300213.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 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) Glengarry Road, 72 DS0000007101.V300213.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. 30th September 2005 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. The CSCI report is discussed with the service user in the service user’s monthly meeting. A copy of the report is placed in the communal area for service user and relative to access. Glengarry Road, 72 DS0000007101.V300213.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 June 2006. The inspector spoke with the Registered Manager and staff, toured the building and looked at records and documents. There were only two service users in the home during the inspection and one of them did not want to speak with the inspector. The other service user said they were very happy, had no problems and did not want to live anywhere else. Most service users have been at this home for around sixteen years and there are no plans for them to move on to other accommodation. The inspector found that things were the same as at the last inspection and the home continues to provide a very high standard of care to the people who live there. What the service does well: Of the standards assessed at this inspection the home showed that: • prospective service users know that the service will fully assess their needs with them, prior to them moving to the home and they can visit the home, meet staff and service users and find out if they like it before they decide to move in permanently. • service users engage with leisure activities, are part of the local community and use local services. • service users are supported to maintain and develop appropriate relationships with their families and friends. • all the procedures and practice within the home respect service users’ rights and ensure that they are supported to take responsibility for their own lives. • the home is run in such a way that service users take responsibility for the day-to-day decisions about the running of the home and are consulted about all aspects of their individual programmes. • service users are supported to take reasonable risks in their lives and if there are any identified areas of risk, action plans are put in place to safely manage or minimise those risks. • service users receive actual personal care or support in the form of prompting, in a way that respects their individuality and dignity and ensures they maintain responsibility for their own care as far as possible. • the procedures and practice around medication storage, handling and administration ensure that service users are protected from harm and that they are supported to take as much responsibility for their own medication as is possible. • day-to-day complaints are taken seriously and action is taken. • service users are protected from harm and abuse. • service users are supported by a fully trained, qualified, supervised and effective staff team Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 6 • • service users know their views underpin how the home will improve. service users’ health, welfare and safety within the home are promoted and protected. 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. Glengarry Road, 72 DS0000007101.V300213.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 Glengarry Road, 72 DS0000007101.V300213.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can know that the service will fully assess their needs with them, prior to them moving to the home and make an informed decision about whether the home can meet those needs. Prospective service users do have the opportunity to visit the home, meet staff and service users and find out if they like it before they decide to move in permanently. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the Statement of Purpose is revised to update all new personnel information and ensure that the written aims and objectives of the home are consistent with the actual aims of the home at the moment. There was a also a previous recommendation that the Registered Individuals should consider revising the homes Statement of Purpose and possibly the registration status of the service (in consultation with the Commission) in order to more usefully reflect the aims and objectives of the service and the current service user group. The Statement of Purpose has been revised and now includes up-todate information about personnel. The Registeerd Manager talked of how they would not consider accepting someone into the home who was in their twenties to forties given the older ages of the current service users. This should be in Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 9 the Statement of Purpose but to avoid the document having to be reviewed again an additional loose sheet can be added into the document to describe the current age ranges of the service users and why younger people would not fit in at the present time. No service users have moved to the home in the last year but at the last inspection the inspector talked through the process with staff and the Registered Manager and assessed what had happened with the service user that had last moved in. The evidence was the same at this inspection and meets the standard. Glengarry Road, 72 DS0000007101.V300213.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in such a way that service users take responsibility for the day-to-day decisions about the running of the home and are consulted about all aspects of their individual programmes. Service users are supported to take reasonable risks in their lives and if there are any identified areas of risk, action plans are put in place to safely manage or minimise those risks. EVIDENCE: The home conducts service users meeting every month and key work sessions with individuals every month (or as required). Service users draw up their own menus and rotas for cleaning, shopping and cooking for the house. 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. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 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, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff work with service users to identify what activities they wish to pursue as individuals and as a group. Service users are offered opportunities to engage with leisure activities are part of the local community and use local services. Service users are supported to maintain and develop appropriate relationships with their families and friends. All the procedures and practice within the home respect service users’ rights and ensure that they are supported to take responsibility for their own lives. EVIDENCE: During the inspection four service users were out at day centres. Staff talked about each service user’s individual activities and the care plans showed that individual programmes are in place to support and encourage service users to go out as they choose. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 12 Four service users are going on holiday together later this year, the other two have chosen not to go. Families are involved in the home as much as they choose. they are invited to reviews and kept informed on day-to-day basis. Last year 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 service users. Service users are supported to visit their families and currently the home is offering to pay for one family member to visit a service user as they are unable to get there on their own. Service users rights are protected. The Registered Manager talked about their awareness and monitoring of one service user’s relationship with their family in case of any potential financial abuse. Service users decide on their own lifestyle in conjunction with staff and have a high level of independence at this home. Staff were seen to respect service users’ privacy on the day of the inspection and treated service users with dignity and respect. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 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 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users receive actual personal care or support in the form of prompting, in a way that respects their individuality and dignity and ensures they maintain responsibility for their own care as far as possible. The procedures and practice around medication storage, handling and administration ensure that service users are protected from harm and that they are supported to take as much responsibility for their own medication as is possible. EVIDENCE: Only two of the six service users require physical personal care the rest just need support and prompting to look after themselves. The care plans show the detail of how personal care is to be offered and service users said that staff are very helpful in these areas. The home operates a robust and effective medication procedure with service users being encouraged and supported to administer their own medication where possible. There were no problems with the medication stocks and records when checked. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 14 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 & 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Day to day complaints are taken seriously and service users know that their views are listened to any action will be taken to address any issues. Service users are protected from harm and abuse by the organisations policies and procedures, by staff practice and training and by staff’s awareness of the service user group and their individual needs and issues. EVIDENCE: The home has a very clear Complaints Procedure that service users are made aware of and there is a complaints recording procedure in place. No formal complaints have been made in the last year. Service users raise any day-today 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. All staff have received vulnerable adults training and the organisation has a comprehensive policy around protection of vulnerable adults. Finances are stored and managed effectively in the home and financial auditing takes place appropriately. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 15 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, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The shared spaces in the home are comfortable and fit with the service users needs. Bedrooms meet the size requirements and are individualised to service users tastes. The home is clean and hygienic throughout. The home needs to do further consultation to ensure that all equipment and adaptations within the home are suitable for the current service users. EVIDENCE: The home is comfortable and homely with three bathrooms and toilets, a separate lounge and dining room and six single rooms. The home is clean and hygienic and service users choose their own furnishings and fittings for their rooms. One service user said they were happy with their room and with the home in general. There was a previous requirement that the Registered Manager must ensure that the Environmental Health Agency is called out to inspect the building and meet any recommendations they may have with regard to ventilation or extractor devises for the dining room (smoking area). This has been done and Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 16 service users now no longer smoke in the dining room. There is now a separate space for service user to smoke. There was a preivous requirement that the Registered Individuals must ensure that an occupational therapists assessment of the entire building takes place to make sure that the individual service users 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. Any recommendations made in that report must then be met as a priority. The standards state than an Occupational Therapist or other suitably qualified professional can conduct these assessments and the organisation uses a firm of consultants to conduct all their health and safety assessments. These consultants had undergone a desktop assessment of the building and said it was acceptable and are due to conduct their annual health and safety audit in July 06. They have said that they will focus on the environment during this audit. The requirement is repeated as the full audit has not taken place but the organisation must also satisfy themselves that the Diploma in Safety Management held by their consultant is equivalent to an occupational therapist’s qualification for the purposes of this work. (See Requirement 1) Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 17 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, 34 & 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by a fully trained, qualified, supervised and effective staff team, which means that they are offered a high standard of quality care. EVIDENCE: Four of the five permanent staff hold or are undertaking the NVQ Level 3 in care or higher. 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. The Registered Manager and staff commented that the organisation’s training is particularly good and there is no area of training that the staff team as a whole or as individuals have not had met. The rota showed that there are sufficient numbers of staff on duty to meet the needs of the service users and the Registered Manager and staff stated that they believed there were enough staff at the home. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 18 The personnel files were not available for inspection as the organisation keeps these at its head office. The home has a record of the Criminal Records Bureau checks undertaken and the CRB number for each staff member. No new staff have been recruited in the last year. There is an appropriate recruitment and selection procedure for the organisation. The Commission now has a form that has to be held on file for all staff which is a form of checklist for recruitment records and which is signed by one of the Registered Individuals. (See Requirement ) The records showed that staff are offered supervision monthly and that all required areas are covered. Staff are offered support and development time within these sessions. Staff said they get good supervision, that it happened monthly and they can ask for extra session if they need it. Appraisals occur annually. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 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): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management of the home ensures that the home is well run and all systems and procedures are operated effectively. Staff are supported by management to comprehensively meet service users’ needs. The organisations systems for gathering service users’ views and developing the service provided based on their views means that service users know their views underpin how the home will progress and improve. All procedures and systems for monitoring health and safety issues are used effectively which means that service users’ health, welfare and safety within the home are promoted and protected. EVIDENCE: The Registered Manager has completed both the Registered Managers Award and the Care NVQ Level 4 qualifications. She has been the manager of this Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 20 service for around five years and has around ten years experience in this field. Throughout the inspection she showed her ability to manage this service and ensure the needs of the service users are met. Staff said that the two managers at the home were excellent, supportive and always listened to them. The organisation is one that places a considerable emphasis on quality control. The home establishes annual objectives that are based on service users talking about what they have experienced at the home and what they want to improve. The home operates PQASSO (Practical Quality Assurance System for Small Organisations) system of quality assurance and the records showed that this is progressing with action plans being developed every year to improve service delivery. The home has a business plan that states how the home aims to improve over the next year. All health and safety records were viewed. Audits take place annually and are monitored throughout the year. The last year’s action plan has been put in place to meet the recommendations of the last audit. Fire records are all in place as are all required system and equipment checking and certification. The home was hygienic and on the tour of the building no health and safety issues were noted. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 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 3 3 X 4 X 5 X 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 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 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 YA29 Regulation 23(2)(n) & 13(4)(a)&(c) Requirement Timescale for action 31/07/06 2. YA34 19 (1) (b) The Registered Individuals must ensure that an occupational therapists (or other suitably qualified professional) assessment of the entire building takes place to make sure that the individual service users 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. Any recommendations made in that report must then be met as a priority. Previous requirement: Unmet timescale 30/11/05. The Registered Individuals must 30/09/06 ensure that the Commission’s recruitment form is completed for all staff and held on file at the home. Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 23 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 Glengarry Road, 72 DS0000007101.V300213.R01.S.doc Version 5.2 Page 24 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. 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