Inspection on 01/12/05 for Good Neighbours House

This inspection was carried out on 1st December 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Good Neighbours House 22/05/09

Good Neighbours House 12/06/08

Good Neighbours House 26/11/07

Good Neighbours House 14/11/06

Good Neighbours House 18/08/05

Good Neighbours House 30/12/04

Good Neighbours House 17/05/04

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

CARE HOME ADULTS 18-65 Good Neighbours House 38, Mary Datchelor Close London SE5 7AX Lead Inspector Ms Alison Pritchard Unannounced Inspection 1st December 2005 5.30pm Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Good Neighbours House Address 38, Mary Datchelor Close London SE5 7AX 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) 0207 703 7451 0207 252 7105 SCOPE Pasteur Djatchi Care Home 16 Category(ies) of Physical disability (0), Physical disability over 65 registration, with number years of age (0) of places Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 16 (sixteen) people with physical disability some of whom may be over 65 years old. 18th August 2005 Date of last inspection Brief Description of the Service: Good Neighbours House is a purpose built care home which provides care and accommodation for up to sixteen adults who have a physical disability. The home is fully accessible to people who use wheel chairs. Each resident has his or her own room. The home has three floors, access to the upper floors is by stairs or the two passenger lifts. None of the bedrooms on the upper floor is in use. Three residents live in accommodation which is used to develop independent living skills and, as appropriate, to facilitate a move to independent living in the community. The home is located close to the centre of Camberwell where there is a busy shopping centre, banks, restaurants and pubs. Public transport routes are close by. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, carried out over the early evening in early December 2005. The inspection methods included a partial tour of the building, discussion with four residents, observation of care practice, discussions with staff members, the manager and examination of records. The majority of the core standards had been inspected at the previous inspections of April and August 2005. As a result this inspection focussed on the compliance with previous requirements. What the service does well: 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 Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 6 contacting your local CSCI office. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: At the announced inspection standards 2 and 5 were examined and found to be met. None of the standards from this group were examined at this inspection. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 The residents will benefit from the improvements planned to the key working system and the audit of files which is underway. Care needs to be taken to ensure that decisions made at review meetings are followed through. Residents will be afforded greater protection and support if risk assessments are conducted in relation to activities which may present risks to them. EVIDENCE: At the announced inspection it was found that the residents would benefit from improvements to the care planning process including regular reviews, effective consultation with relatives, file audits and reallocation of key work duties in the absence of the permanent post-holder. Since then a number of improvements have been made and are planned. It is planned that the system for key working be changed so that each resident has two key workers. This will allow the second member of staff to cover key work duties in the absence of the main allocated key worker. It was required that an audit of files be undertaken to ensure that documents are dated, signed and currently relevant. This was not examined in detail at this inspection as it was within timescale. Arrangements have been made to Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 10 ensure that reviews of residents’ care plans are conducted at six monthly intervals, or more frequently as necessary. One care plan was examined in detail during this inspection. Notes of a review held in May 2005 were available. It was found that there was no evidence to indicate that decisions taken at the review meeting had been actioned. These were the need to conduct a risk assessments about the resident’s ability to use public transport, the use of the bathroom and in relation to medication management. It was also agreed that arrangements would be made to have an independent advocate visit the resident. An additional meeting had been held in mid-November 2005 in response to a particular concern. Another area of concern relating to risk assessments was that although the resident was undertaking cooking with the assistance of staff there were no detailed guidelines regarding this, nor was there a risk assessment to support the activity. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 The residents should benefit from a staff team who have received training in the provision of activities for disabled people. EVIDENCE: All of these standards were examined at the announced inspection of August 2005. It was found that in relation to standard 11 residents would benefit if the care planning system gave more emphasis to residents’ opportunities for the maintenance and development of skills in keeping with their wishes and goals. All of the other standards were met. The Registered Manager has informed the CSCI that there is a review of the care planning system underway to ensure that residents’ wishes and goals in relation to skills development are more closely reflected in the care plans. The target date for compliance with this requirement was 1st March 2006 so the progress towards meeting the requirement was not examined at this inspection. The staff undertook training in the provision of suitable activities for residents of the home and it is anticipated that this will be reflected in the residents’ opportunities to take part in age, peer and culturally appropriate activities. This will be fully examined at the next inspection of the home. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 12 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 The home manages medication well. Generally residents’ healthcare needs are met but when residents have falls or are unwell the residents would benefit if there was more active management monitoring of the person’s condition. EVIDENCE: Standards 18, 19 and 20 were examined at the announced inspection in August 2005. Further examination of these standards related to two residents. Review of a resident’s care notes showed that there had been a recent issue in relation to the manner in which care had been provided and that this had a negative impact on the particular resident. Discussion with the resident and a senior member of staff showed that there had been action in response to the issue and changes made as a result. It was found that if a resident refused to take medication then it was appropriately reported to the GP, and as necessary to other professionals. An instance of a resident’s non-compliance with the medication regime had resulted in a multi-disciplinary meeting being held and guidelines being drawn up to ensure that the risk of recurrence was minimised. There was evidence from a range of sources that the matter was dealt with appropriately and that it was not a current problem. Medication is appropriately stored. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 13 One resident had experienced a fall some weeks before the inspection. It was found that medical advice had been sought on the day after the fall and again nine days later. The notes showed that there was a significant deterioration in the resident’s condition within this period. This was later found to be as a result of a different complicating medical factor. The resident has now recovered from the problem but there were indications that more active monitoring by senior staff may have been beneficial to the resident had they sought medical advice at an earlier stage. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 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 The residents will benefit from the improvements to the systems to record complaints which have been made since the last inspection, and also to the checks of property lists which will soon be completed. EVIDENCE: Residents confirmed that they are aware of how to raise concerns, both within the home and by using the organisation’s complaints procedure, which is described in leaflets available in the home. One resident informed the inspector that a matter of concern had been dealt with to their satisfaction and that they wished no further action to be taken. The Registered Manager informed the CSCI that the complaint system has recently been reviewed to ensure that the outcome of complaints and the action taken to address any issues raised will be recorded. An audit to ensure that residents’ property lists are complete will be undertaken by the end of December 2005. This will provide further protection for residents. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 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): 26, 30 The residents who use the independence kitchen on the first floor would benefit from improvements being made to the standards of hygiene in the room. EVIDENCE: All but one (standard 26) of these standards was examined at the last inspection of the home. On this occasion one bedroom was seen and found to be in good order and the resident expressed satisfaction with the facilities. A kitchen used by two residents as part of an independent living training programme was seen. The kitchen was in need of some improvements, specifically: • • • The microwave was very dirty and needed to be cleaned The bin was in poor condition and needed to be replaced There was no thermometer available in the refrigerator for monitoring the temperature to ensure that food storage facilities are safe Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 16 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, 36 There are enough staff on duty to make sure that residents’ needs for care and support can be met. EVIDENCE: At the last inspection it was found that the staffing levels sometimes dropped below the agreed level which is for there to be four members of staff on duty at all times of the day and two staff on duty overnight. At this inspection there were sufficient numbers of staff on duty at the time of the inspection and the rota showed that these staffing levels are maintained. At the weekend there is no cook available so catering duties are covered by a member of the care staff team. The registered manager should provide an assurance that the allocation of a member of care staff to catering duties does not result in these staffing levels being reduced. There are now systems in place to ensure that staff receive supervision at least six times a year and an appraisal system has now been introduced. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 17 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, 41, 42 Residents benefit from the management systems which ensure that they are consulted about the way the home runs. EVIDENCE: The Manager has been registered under the Care Standards Act since 2002. During the inspection the Registered Manager showed the inspector an action plan which had been drawn up in consultation with staff. The plan had been drawn up at a recent staff meeting and it demonstrated an open approach to the management of the home to which staff have input. Monthly visits are made to the home as required regulation 26 of the Care Homes Regulations. A senior manager from Scope conducts the visits and reports are forwarded to the CSCI. The reports show that the visits include consultation with residents, the manager and with staff and cover a range of topics relevant to assessing the operation of the home. The home now informs the CSCI of a wider range of incidents which occur, but some incidents had not been notified, this was discussed with the manager Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 18 who agreed to ensure that this is improved. It has been noted since the inspection that action has been taken to ensure that this is the case. Improvements to the conditions in the independence kitchen on the first floor will improve the health and safety arrangements for the resident who use that kitchen. Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 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 x 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 x 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 3 x 3 2 x Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 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 YA6 Regulation 15(1) Timescale for action The Registered Person must 01/03/06 ensure that an audit of residents’ files is conducted to ensure documents are dated, signed and currently relevant. This was within timescale at the time of the inspection and so was not examined. The Registered Person must 01/03/06 ensure that care planning systems are improved by ensuring that there is reference to skills development, enabling residents to maintain their skills, to be given opportunities to use them and have the chance to learn new skills in keeping with their wishes and goals. This was within timescale at the time of the inspection and so was not examined. 3 YA23 13(6) The Registered Person must 01/01/06 ensure that an audit of residents’ property lists is undertaken to ensure that they are complete. This was within timescale at the Good Neighbours House DS0000007106.V258504.R01.S.doc Version 5.1 Page 21 Requirement 2 YA6YA11 12, 15(1) time of the inspection and so was not examined. 4 YA6 15(2)(c) The Registered Person must ensure that decisions made at review meetings are implemented within a reasonable timescale. The Registered Person must ensure that a risk assessment is in place to support residents’ use of the independence kitchen. The Registered Person must ensure that there is a system in place to ensure active monitoring by senior staff of residents who have been unwell or have had falls. The Registered Person must ensure that improvements to the standards of hygiene are made in the independence kitchen on the first floor. 01/04/06 5 YA9 13(4)(b) 01/04/06 6 YA19 13(1)(b) 01/04/06 7 YA30YA42 23(2)(d) 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA32 Good Practice Recommendations The Registered Manager should ensure that the allocation of a member of care staff to catering duties in the absence of the cook does not result in care staffing levels being reduced. 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