CARE HOME ADULTS 18-65
Gonville Road (33) Bovell`s Lodge 33 Gonville Road Thornton Heath Surrey CR7 6DE Lead Inspector
Claire Taylor Unannounced Inspection 11:00 15 & 28th November 2005
th Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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 Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Gonville Road (33) Address Bovell`s Lodge 33 Gonville Road Thornton Heath Surrey CR7 6DE 020 8683 4802 020 8683 4802 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) Wilfred Bovell Barbara Ellaine Bovell Mr W Bovell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Number of service users for whom accommodation or services may be provided (if applicable) three (3) Number of service users permitted in each category LD Learning disability 13 May 2005 Date of last inspection Brief Description of the Service: Bovells Lodge is a small care home registered with the Commission for Social Care Inspection to provide a service for three young adults who have learning disabilities, aged between 18 and 65 years old. The registered provider, Mr Bovell, is also registered as the manager and is therefore very involved with the home. Situated in a residential area of Thornton heath, the home is well positioned to access local transport links and amenities. The registered provider also has a car to enable service users to access their chosen activities. The premises consist of three good- sized single bedrooms on the first floor, communal lounge, open plan dining / kitchen area, laundry and office. There is a garden to the rear of the house comprising of lawn, various fruit trees and patio area. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours and the report is based on findings from two visits made to the home. Inspection time was spent talking to the manager /owner Mr Bovell, his wife who also works in the home and one service user on return from his day care centre. The other two service users who live in the home were out at their work placements on both occasions and were not available to comment. A brief tour of the home was made and a number of care records were looked at. Some concerns were identified during the first visit and as a consequence an official letter known as an “immediate requirement” was delivered to the owner on the following day. This advised that the identified concerns must be put right within 7 days or enforcement action would be taken. A second unannounced visit was undertaken on the 28 November 2005 and the registered provider had dealt satisfactorily with the matter within the given timescale. All key standards were assessed at the home’s previous inspection in May 2005 and the reader is therefore referred to that report should they require any further information. What the service does well: What has improved since the last inspection?
At the previous inspection there had been six areas in which the home had to improve. The home has taken action on all but two of these areas which represents a positive response and demonstrates the provider’s commitment to further raise the standards at the home. Training for staff has improved resulting in a more skilled workforce to meet the service users needs. Examples include achieved training on protection of vulnerable adults, fire safety and infection control. Two service users have associated mental health needs and as previously required, the provider has submitted an application to amend the home’s registration category to reflect this. The manager has worked well to ensure that the home can continue to meet their needs i.e. staff have received specialist training and appropriate links are maintained between the home and relevant professionals involved with the service users.
Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 6 Improvements have been made to the home environment including the provision of a new dining table and chairs and dishwasher. “Sky” television has been installed in two of the service users bedrooms at their request. 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. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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 Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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): X None of these standards were assessed on this occasion. Standards 2,3,4 and 5 were assessed as met at the May 2005 inspection. EVIDENCE: Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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): 6,7, and 9 Care plans provide staff with the information they need to satisfactorily identify and meet the service users’ personal, social support and health care needs. Service users are consulted about how the home operates and are enabled to make decisions about their lives. Individuals are provided with the necessary support to take risks so that independence is maximised as far as possible. EVIDENCE: Service user plans are developed from needs assessments and cover in sufficient detail all aspects of personal, social support and health care needs of each individual. Care plans were being evaluated, regularly reviewed and updated accordingly to reflect changing needs. Reviews are held and involve the service user, their relatives/ representatives, other professionals and Care Management. Records showed that agreed actions from the most recent review meeting for one service user had been addressed. I.e. Person centred planning has recently been implemented. Areas covered include a pen portrait of the service user, details of their social network, activity timetable and communication profile. Pictures and symbols are included to make the plan more accessible and meaningful to them. A health action care plan has also been developed for the service user in a similar format. The manager stated that he plans to use photos to personalise the plan further. Records and
Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 10 discussion showed that staff support service users to make decisions about their lives. An example was where one service user recently chose to be baptised at his local church and was fully supported to follow his wishes. All the service users are supported to take ‘responsible’ risks as appropriate. Relevant risk assessments, matched to individual needs were up to date and well written to guide staff on how to protect individuals from potential harm. E.g. safety around the home and accessing the home / wider community. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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, 16 and 17 Service users are supported to continue education and appropriate activities within the home and local community so that they can maximise fulfilment and achievement in their lives. Staff treat service users with respect, value their individuality and promote their individual rights. Meal provision reflects variety and choices, whilst seeking to maintain a healthy lifestyle for service users. Standard 15 was assessed as met at the May 2005 inspection. EVIDENCE: Records showed that the service users have opportunities to take part in a variety of stimulating activities both inside the home and in the wider community. Social needs are clearly described within the care plans that take account of service users preferences. Recent social events for service users have included a holiday to Great Yarmouth and trips to “Legoland” and Blackpool. Two of the service users are very independent, have an established relationship and often go out together on community activities. They both access public transport independently and were out at their work placement
Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 12 during this inspection. Records confirmed that service users are supported to engage in activities of their choice. As well as regular day care, the third service user is supported to attend a karate club on a weekly basis, shopping trips and church. He confirmed that he enjoyed his activities. The registered manager / provider uses his own car to support the service user to access his chosen activities. Although records showed that service users are offered choices and supported to make decisions, formal meetings should be held at more frequent intervals. (The last service users meeting was held in April of this year) This would further ensure that service users are consulted regularly about the care provided and that their views have an influence on the way the home is run. The menus are planned around service users choices. Mealtimes are arranged flexibly to suit individual work and activity schedules. Food provided is nutritious and offers a well balanced diet. Any concerns that may arise over service users diet or nutritional needs are referred appropriately to either the GP or dietician. Service users are weighed on a regular basis. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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 Suitable arrangements are in place to ensure that service users’ physical and emotional health care needs are identified, planned for and met. Personal care is carried out in a way that service users prefer so that dignity and choice are maintained. Some improvements are needed with the home’s medication systems, to ensure that safe practice is maximised and service users are not put at risk. EVIDENCE: Times for getting up and going to bed are flexible and arranged according to the service users’ lifestyle and daily routines. Two service users are fully independent in personal care and this was reflected in their respective care plans. Specific goal plans are in place for one service user to develop their personal care skills. Information relating to personal and healthcare needs including both routine and one off health interventions were well recorded. Care plans and specific strategies identify individual and specialist needs, which also reflect any changing needs. Detailed records were in place and involvement with specialist services highlighted. E.g. counselling group for one service user. Some concerns were identified in relation to the home’s systems for management of medication. The medicine cupboard contained large quantities of medication prescribed for service users that had been either discontinued or were surplus to requirements. Records for the receipt or disposal of medication were not available and there was no profile to identify
Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 14 the current, prescribed medication for one service user. In addition, medication administration records were not available for this service user. Such shortfalls could increase the likelihood of mishandling and general unsafe practice, putting people at risk. An immediate requirement was therefore issued on the 15 November 2005 with a follow up visit undertaken on the 28 November to check compliance. Evidence was seen that the registered provider had taken the required action and complied within the given 7-day timescale. I.e. Unused medication had been returned to the pharmacy and records put in place for the receipt and disposal of all medication. Records showed that all medicines administered were being signed for appropriately on MAR sheets. Additionally, the home’s medication policy had been revised to reflect the changes. At the last inspection, all staff were required to attend a suitable medication training course. Records showed that training had been booked for the new staff member on the day following this inspection. The manager had also obtained a medication training pack from “Mulberry Care” that includes distance-learning objectives for staff to complete. Progress will be checked at the next inspection. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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): 22 and 23 The home operates a clear and effective complaints procedure that is available to all the homes service users in a suitable language/format. There are procedures and systems in place regarding adult protection and prevention of abuse. Since the last inspection, improvements have been made to maximise protection for the service users. EVIDENCE: A clear complaints procedure is available in the home. The version has been formatted with symbols and pictures to make it more accessible to the service user who cannot read. No formal complaints have been made about the homes operation in the past twelve months. The home’s practices concerning adult protection have improved significantly since the last inspection. Following a missing person incident during the service users’ summer holiday, a meeting was held under the auspices of Adult Protection on the 6th September 2005. This concerned one service user who has a history of leaving his surroundings without informing relevant staff / carers. Various strategies and actions agreed at the meeting were checked during this inspection and had been actioned by the registered provider. I.e. Each service user now carries a personal identification card, which includes emergency contact details for when they are away from the home. The home’s missing person policy has been revised to ensure that staff follow appropriate guidelines and take action more promptly should a service user go missing. E.g. relevant parties such as the care management team must be notified when service users go on holiday. Risk assessments for the service user had also been reviewed appropriately to ensure that the service user’s welfare is better safeguarded. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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, 26 and 30 The home is clean, decorated and furnished to a good standard and provides service users with safe, comfortable surroundings in which to live. Bedrooms are designed and furnished according to the personal preferences and individual lifestyles of the service users. EVIDENCE: There have been some refurbishments since the last inspection including the provision of a new dining table and chairs and new dishwasher. A brief tour of the premises was undertaken and all three service users’ bedrooms were viewed. All areas of the home were found to be clean, tidy and free from odour. Service users are encouraged and supported to choose how to decorate their rooms and have personalised them according to their preferences. At their request, the registered provider has arranged for two service users to have “Sky” television installed in their bedrooms. A fire safety inspection was carried out by the London fire and emergency planning authority in November of this year. The premises were assessed as satisfactory and in meeting with current fire regulations. Good hygiene practices are observed and the home once again, appeared clean, tidy and free from offensive odours. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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): 34, 35 and 36 Recruitment practices are securely managed to maximise protection for the service users. Training for staff has improved since the last inspection resulting in a more skilled workforce to meet the service users’ needs and home’s aims and objectives. Improvements are needed with staff supervision arrangements to ensure that service users benefit fully from a well-supported staff team. Standard 32 was assessed as met at the May 2005 inspection. EVIDENCE: The registered manager / provider, his wife and one part time care assistant currently provide all staffing in the home. The manager advised that he plans to recruit one more staff. A new staff has been appointed since the last inspection and joined in September of this year. Their personal file was examined and contained all the required documentation to evidence their fitness to work with this service user group. I.e. completed checks including CRB/POVA; two references, proof of identity and training certificates. The new staff was in the process of induction to the home and learning topics include the particular needs of the service user group, the worker’s role in the home and general principles of care. Good progress has been made with regards to staff training and previous requirements addressed. Certificates showed that training undertaken since the last inspection has included infection control, adult protection and fire safety. Staff have received training on mental health awareness meaning that they are better equipped with skills and knowledge to
Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 18 meet service users needs. As previously required, supervision arrangements for staff needs to be improved upon to fully meet the standard. Records must be kept to show that career development / training needs of each staff have been discussed and actioned. Supervision should identify what the member of staff does well, what they may need to improve upon and what training they may need. This requirement is therefore repeated. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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, 41 and 42 The manager, also the homeowner, has good experience and professional qualifications relevant to managing the home. The home’s policies/ procedures and codes of practice mean that service users’ rights and best interests are safeguarded. Standard 39 was assessed as met at the May 2005 inspection. EVIDENCE: The manager/owner demonstrated a sound knowledge of the service users specific needs and has periodically attended various training courses to keep his knowledge and skills up to date. Mr Bovell has at least five years experience working with adults with learning disabilities and has been in operational control of the home since it opened in 2003. He has achieved a relevant management qualification and an NVQ level 4 qualification in management and care. The home’s policies and procedures are more organised enabling better clarity and access for staff. Overall, health and safety practices are well observed. The servicing and maintenance records for the home were sampled at random and generally up to date. One requirement remains outstanding from the previous inspection however. I.e. environmental
Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 20 hazards around the home must be risk assessed to safeguard the welfare of the service users and minimise the risk of injury. Records showed that staff have now received training in key health and safety topics such as first aid, infection control and fire safety. Plans are in place for the new member of staff to attend such training. Fire drills are organised at regular intervals although it is recommended that records should include the time of day, who was involved and the time taken for people to evacuate. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Gonville Road (33) Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X 3 2 X DS0000028514.V266520.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES- 2 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 YA20 Regulation 13(2) Requirement The registered person must maintain records for the recording, handling, safekeeping, safe administration and disposal of medication. (Immediate requirement issued 15.11.05 and complied within given timescale) The registered person must ensure that medication administration charts are maintained for all service users. (Immediate requirement issued 15.11.05 and complied within given timescale) The registered provider must ensure that each member of staff has formal documented supervision at least six times per year. (Timescale from previous two inspections not met) Risk assessments concerning safe working practices around the home need to be completed. (Timescale of 31/08/05 not met)
DS0000028514.V266520.R01.S.doc Timescale for action 23/11/05 2. YA20 17(1a) Sch 3 (3 i ) 23/11/05 3. YA36 18(1a)(2) 31/12/05 4. YA42 13(4) 15(1) 31/12/05 Gonville Road (33) Version 5.0 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. 1. 2. Refer to Standard YA42 YA16 Good Practice Recommendations Fire drills records should include the time of day, who was involved and the time taken for people to evacuate. Service users meetings should be held at more regular intervals. Gonville Road (33) DS0000028514.V266520.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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