This inspection was carried out on 24th August 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Glengarry Road 72 Glengarry Road London SE22 8QD Lead Inspector
Lisa Wilde Unannounced 24 August 2005, 10:00am
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 72 Glengarry Road Address 72 Glengarry Road, London, SE22 8QD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8693 6743 Southside Partnership Mrs Abimbola Adewunmi Ogunbadejo CRH Care Home PC Care Home Only 6 Category(ies) of MD Mental Disorder registration, with number MD(E) Mental Disorder - 0ver 65 of places Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 6 people male or female with mental disorder other than dementia some of whom may be over 65 years old. Date of last inspection 3rd February 2005 Brief Description of the Service: 72 Glengarry Road is a care home providing personal care and accommodation for 6people 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 located in Dulwich, South London, close to shops, pubs, the post office and other amenities.The home consists of a three-storey 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. Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 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 2005. The deputy manager was at the home but the manager was on annual leave. As the previous inspection had taken place without the manager present as well it was decided that the next inspection of this service would take place quite quickly (at the end of September) and would be announced to make sure the manager was present and could add her views into the process. This inspection was quite brief as the deputy manager was on shift at the service and needed to spend his time supporting service users. As the next inspection will be announced, the manager will have enough notice to organise appropriate cover to allow her to spend her time on the inspection. What the service does well:
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. Service users take part in drawing up plans for their care and these are written down to outline action staff must take to meet their needs and support them to achieve their goals. These care plans are reviewed regularly which means that service users can know that as their needs change the staff support will change around them. Staff understand service users physical and emotional health needs and record any issues on the files. This means that service users can be sure that all staff know what to do to support them to maintain their physical and mental health. Service users are generally supported by the homes’ policy and practice around medication administration (although there is one area that needs further work see below). 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, using local services. Service users are offered a varied diet, of their choosing, that reflects the cultural needs of the group. The home is comfortable and decorated in a way that suits the wishes of the service user group. On the day of the inspection the home was clean and hygienic throughout. Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 6 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.
Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 4 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: The home’s Statement of Purpose was not assessed in detail but the inspector noted that although the home is registered for adults aged 18-65, four of the current six service users are over sixty-five with one at sixty one. This is allowable given the additional condition that allows the home to give accommodation to some service users aged over sixty five but the inspector was concerned that actually now the home has become one for older people whereas it is still registered for younger adults and being assessed against the younger adult standards. The deputy manger and member of staff considered themselves to be working in a home for older service users and as such a recommendation is made regarding the statement of purpose and this will be further discussed with the manager at the next inspection. (See Recommendation 1) A service user had moved to this home about six months ago and had visited the home several times during the day before they moved in. Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 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 standard(s) 6 & 9 Service users take part in drawing up plans for their care and these are written down to outline action staff must take to meet their needs and support them to achieve their goals. These care plans are reviewed regularly which means that service users can know that as their needs change the staff support will change around them. Service users may be being placed at some risk at this home given that risk assessments around falling and mobility have not been conducted and the service users are older and have rooms on the first and second floors of the home. EVIDENCE: The inspector looked through all six service users care files and found them to be comprehensive and consistent. Care plans and risk assessments are in place that identify staff action to meet service users needs and minimise risks. All areas of service users’ lives are assessed and the care plans are written with their involvement. Reviews of care plans take place monthly at the home with CPA reviews taking place with other professionals every year. Environmental risk has not been assessed at the home specifically and given the number of older people at this home it is necessary for risk assessments to
Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 11 be in place around mobility and falls especially as none of the bedrooms in this home are in the ground floor. (See Requirement 1) Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 17 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, using local services. Service users are offered a varied diet, of their choosing, that reflects the cultural needs of the group. EVIDENCE: During the inspection all service users were either out at day centres, taking part in shopping for the home or doing their own personal chores. 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. The menus were seen and were varied and healthy. The food being cooked for lunch was healthy and prepared in an attractive manner. Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 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 standard(s) 19 & 20 Staff understand service users physical and emotional health needs and record any issues on the files. This means that service users can be sure that all staff know what to do to support them to maintain their physical and mental health. Service users are generally supported by the homes’ policy and practice around medication administration although there is one area that needs further work. EVIDENCE: Care plans showed that all service user healthcare needs are being addressed. The deputy manager reported very few concerns with the current service users health. Referrals are made to specialist services as needed and service users are supported to attend appointments. When service users decline to access the community for their regular healthcare appointments efforts are made to bring the GP and other clinicians into the home. Some service users administer their own medication with staff spot-checking on occasion. The medication records and stocks were checked and the systems were found to be robust and effective. No errors were found in the recording and administration of medication but the home must record any investigations that it makes into medication errors on the medication administration sheets. There must also be a list kept of all staff who are authorised and trained to administer medication. (See Requirements 2 & 3) Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 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 standard(s) X These standards were not assessed, at the last inspection they were met. EVIDENCE: Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 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 standard(s) 24, 27, 28, 29 & 30 The home is comfortable and decorated in a way that suits the wishes of the service user group. One area of the building smelt strongly of smoke and may be putting service users at risk with regard to smoke inhalation. The home has not initiated the appropriate assessments for all specialist adaptations and equipment at the home which means that service users may be put at risk. On the day of the inspection the home was clean and hygienic throughout. EVIDENCE: The home has a lounge and separate dining area which is currently used as the service users’ smoking area. The dining area smelled strongly of smoke and is not the most appropriate area to be designated the smoking area (See Requirement 4) The bathrooms were clean and decorated in a homely manner. The home has some wall bars and other adaptations to make the use of baths etc easier but the home has not been assessed by an occupational therapist with regard to specialist equipment or adaptations or with regard to the
Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 16 number of stairs that have to be negotiated by service users. Given the older service user group at this home this work is necessary. (See Requirement 5) There was a previous requirement that the home must ensure that wash hand basins and tiling are kept clean. On the day of this inspection the home was clean and hygienic throughout. Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) X These standards were not assessed during this inspection. EVIDENCE: Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) X These standards were not assessed during this inspection EVIDENCE: Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 3 x Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 x x 2 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x 3 3 2 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Glengarry Road Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 20 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 YA9 Regulation 13 (4) (a) & (c) Requirement The Registered Manager must ensure that risk assessments are undertaken for all service users with regard to falls and other mobility issues. The Registered Manager must ensure that a list of all staff authorised and trained to administer medication is kept at the home. The Registered Manager must ensure that all investigations into medication administration errors are recorded one the medication administration sheets. 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). 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 Timescale for action 14/09/05 2. YA20 13 (2) 14/09/05 3. YA20 13 (2) 14/09/05 4. YA24 13 (4) (a) & (c) 31/12/05 5. YA29 23 (2) (n) 13 (4) (a) & (c) 30/11/05 Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 21 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.. 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 YA1 Good Practice Recommendations 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. Glengarry Road G52-G02 S7101 Glengarry Rd V246854 240805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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
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