This inspection was carried out on 15th June 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOME ADULTS 18-65
100 Grosvenor Terrace London SE5 0NL Lead Inspector
Lisa Wilde Unannounced 15 June 2005, 10:0am
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. 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 100 Grosvenor Terrace Address 100 Grosvenor Terrace, London, SE5 0NL 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 7701 5622 Odyssey Care Solutions for Today Celia Denise Bownass CRH Care Home PC Care Home Only 4 Category(ies) of LD Learning Disability registration, with number of places 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 19th October 2004 Brief Description of the Service: The new provider since 1st April 2004 is Odyssey Care Solutions for Today. The homes statement of purpose has been updated to reflect the change of Registered Provider. The home provides care for four women who have learning disabilities and additional needs that arise from physical disability and sensory impairment. It is equipped to provide care for one service user who is a wheel-chair user. All four service users have lived together for many years at this home and view this home as their home for life. The home is located in a residential street close to Walworth Road where there are a range of facilities including public transport routes, shops, pubs and restaurants nearby.The vision statement of Odyssey is an aspiration to:“ A society where a learning disability is not a barrier to somebody’s perceived value or ability to make a meaningful contribution” 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final 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 June 2005 when service user reviews were taking place. The last inspection had been announced and most of the standards had been assessed and met. This inspection was mainly about talking with service users’ relatives, other professionals and staff about what they thought of the home. What the service does well: What has improved since the last inspection?
This was the first time this inspector has been to this home so it is harder to say what has improved. There weren’t many requirements or recommendations from the last inspection and all of them had been met by this inspection. Staff said the home has been getting used to the change in organisation over the past year and they haven’t seen many differences at the home. The manager of the home talked about how she now wants to concentrate on quality of life for the service users and focus on increasing staffing levels so that more than just a basic service is being offered.
100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 6 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. 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 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 standard(s) 3 The home does not currently have high enough staffing levels to ensure that the home can meet its stated aims and objectives i.e. a society where a learning disability is not a barrier to somebody’s perceived value or ability to make a meaningful contribution”. The home is not able to allow service users to go out individually and spontaneously. EVIDENCE: The home had met a previous recommendation saying that the home should seek the views of relatives regarding the type and level of activities on offer at the home. The manager said that this had been done through service user reviews. The inspector spoke with one set of relatives who said that they were happy with the level of activities but it was hard for them to know as they weren’t that involved with their niece on a day-to-day basis ad lived a long distance away. The manager has put a recent request to the organisation to increase the staffing levels as she states that the levels are not high enough currently to allow service users to individually and collectively undertake activities she deems appropriate for people their age. The requirement regarding staffing is made under Standard 33. Staff said that sometimes there were not enough staff to take service users out spontaneously, it had to be planned in advance, especially if transport was required. 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 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 standard(s) 8 Although the service users at this home can not speak, staff at the hoe have known them for a number of years and understand as far as possible how they are communicating. Staff consult as far as possible with service users and offer them choices on a day-to-day basis. Service users families are involved in reviews along with advocates and all attempts are made to involve the service users in the running of the home. EVIDENCE: The service users at this home do not speak and staff have learned how to communicate with them through understanding their movement, gestures and other behaviours. The manager and staff stated that they aim to consult with service users on a day-to-day basis by offering them practical choices e.g. with food and allowing them to choose which option they wanted. Reviews are used to involve service user’s families and advocates. The inspector spoke with service user families who said that they were involved as much as they wanted to be and kept informed of day-to-day issues. 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 10 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) 15 Staff at the home ensure that service users have access to their families and friends whenever they choose and involve everyone in the day-to-day events of the home and the reviews of the service. EVIDENCE: The inspector spoke with relatives of service users who all said that they are kept informed and concluded in the home. They can visit when they choose and are invited to al reviews. Staff discussed how recently they had brought one service user back in touch with their semi-estranged parent and they are now seeing each other again after a number of years. As mentioned earlier in the report the home does not currently have enough staff to fully involve the service users in the community or activities and these are being addressed under Standard 33. 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 11 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) 18, 19 and 20 Staff at the home understand the needs of the service users and are able to offer personal support in the way that they require. Staff ensure that healthcare check ups are carried out regularly and refer the service users to healthcare professionals as soon as any issue is identified. The home is not currently recording the stock and administration of its medication effectively and as such is not able to monitor levels of medication held or given to service users accurately. EVIDENCE: The inspector spoke with staff who discussed at length the personal preferences and health care needs of the service users. All staff showed an in depth knowledge of the issue involved with supporting these service users. Relatives of one service user said they were happy with the level of monitoring and healthcare support that is offered but acknowledged the difficulties involved in identifying healthcare issues quickly when the service user is not able to tell staff that they have some pain or discomfort. One service user wears a helmet to protect their head when they have epileptic seizures. This helmet has been in place for a number of years and staff said that the service user does not appear distressed by it. This situation has not been reviewed as a specific issue for a number of years and this must happen with an epilepsy nurse involved in the decision. (See Requirement 1)
100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 12 The inspector examined the medication stores and records held in the home and found some problems. There was a gap in the recording of two medications and a mistake had been made in the administration of the medication the morning of this inspection but it had not been written down as the member of staff was planning to verbally handover at lunchtime. Staff need to undertake rectal diazepam training again as this has not been done for years. Three medications were stock checked and two of the amounts did not tally with the records and the manager stated that due to staffing issues sometimes the stock checks did not take place. (See Requirement 2,3,4 & 5) 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 13 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) 22 Generally the home does all it can to make sure that service users and their families feel they are listened to and their views acted on however the complaints policy does not have the correct contact details for CSCI so anyone wishing to complain to someone other than staff would not be able to do so. EVIDENCE: The home has an appropriate policy and procedure for complaints in place but the details of the CSCI office are incorrect. (See Requirement 6) The manager said that she aims to speak with service users and their families on a day-to-day basis and find out what they feel without them having to resort to making a formal complaint. 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 14 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, 25, 26, 27, 28, 29 & 30 Generally the home is clean, homely and attractive. Service users have individualised bedrooms that are decorated to meet their own tastes and the numbers of toilets and bathrooms mean that they have sufficient privacy. The equipment and adaptations that are used in the home have been assessed by occupational therapists to ensure they meet the needs of the service users. The home is not able to carry out routine maintenance issues efficiently as there isn’t currently clarity about who has responsibility for maintenance issues. The home isn’t currently offering a totally hygienic laundry service as soiled linen is being washed in the machine in the kitchen and not in the laundry room. EVIDENCE: On this inspection the home was clean and free from odours. The service user rooms were decorated to their individual tastes and include all the required fittings and furniture. Thee were some maintenance issues; fixing the broken staff shower, replacing tiling and flooring in the first floor bathroom and replacing cupboard doors in the kitchen which must be met. The manager and staff said that since the
100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 15 handover of this service from Southwark Social Services to Odyssey last year they have been having problems getting maintenance issues dealt with quickly. The manager said that there is no clarity about who is responsible for different repairs and this means that when an issue comes up it cannot be dealt with within the required time. (See Requirement 7) All of the service users have a single room. There are three bedrooms on the first floor of the home and one on the ground floor. The ground floor bedroom is for a wheel-chair user and is below 12 square metres but the relatives of this service users said they are happy with this room and do not want to move. There is enough room to manoeuvre the wheelchair around the room and they said the service user is unable to move their chair without staff assistance anyway and so would not appreciate any additional space. The bedroom on the ground floor has a bathroom and toilet next to it. The home has conducted Occupational Therapy assessments for its service users who need to use adaptations and equipment and updates these every time someone’s needs changes. The laundry facilities are located in the kitchen and do not meet the requirements of standard 30.2. The work to relocate the laundry was being done at the time of the last inspection and was due for completion in November 2004 but has still not been done. The manager stated that this was due to be completed in the next few weeks. (See Requirement 8) 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Service users are not supported by a fully effective staff team as there are not currently enough staff to ensue that service users can go out and undertake activities on an individual basis or ‘as they choose’. Events have to be booked well in advance and cannot be spontaneous. EVIDENCE: The staff team reflects the service user mix in terms of ethnicity and gender. As mentioned earlier in the report the manager has put an application to the organisation for additional staffing as she cannot ensure that service users are receiving enough support to access the community and undertake activities. (Se Requirement 9) 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 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 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) 38 & 42 Staff and professionals stated that the manager was good for the home and service users. Staff said that they were clear about the management approach and service users benefit from a management style that is inclusive and creative. The home is run in a way that protects the health and safety of the service users. EVIDENCE: The manager discussed their management style and role with the inspector throughout the inspection. She showed an understanding of the home and the current issues for staff and service users. Staff described the manager as supportive and external professionals described her as bubbly, lively and committed to the needs of the service users. Relatives described the new deputy manager as very caring. Throughout the inspection, looking at records and tour of the building the inspector found no cause for concern with regard to health and safety other
100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 18 than has already been mentioned under the medication standard, staffing and environment standards. 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final 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 2 x x Standard No 22 23
ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x 3 x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 x x x x 3 x x Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
100 Grosvenor Terrace Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 14 (2) (a) Requirement The Registered Manager must ensure that a review takes place of the use of the helmet for one service user, invovling all members of the care team with an additional Epilepsy Nurse. The Registered Manager must ensure that all mistakes in administration are recorded immediately on the medication administration sheet and not just verbally reported. The Registered Manager must ensure that effective stock checks take place regularly and stock levels are recorded accurately on the medication adminstration sheets. The Registered Manager must ensure that all staff attend training in the administration of rectal diazepam. The Registered Manager must ensure that all medication given is recorded on the medication administration sheets. The Registered Manager must ensure that the correct contact details for CSCI, along with a brief explanation of their purpose, is included in the Timescale for action 30/09/05 2. 20 13 (2) 31/07/05 3. 20 13 (2) 31/07/05 4. 20 13 (2) & 18 (1) (c) (i) 13 (2) 30/09/05 5. 20 31/07/05 6. 22 22 (7) 31/08/05 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 21 7. 24 23 (2) (b) & (d) 8. 30 16 (2) (j) 9. 33 18 (1) (a) Complaints Policy and Procedure and Service User Guide The Registered Individual must ensure that the home is issued with clear guidance about who is responsible for repairs and maintenance in the home and that all necessary repairs are carried out in a timely manner. The Registered Individuals must ensure that the planned laundry refurbishment is carried out as a priority. The Registered Individuals must ensure that the staffing levels at the home are sufficent to fully met the needs of the service users. The Commission must be informed of the outcome of the current staffing review. 31/08/05 31/08/05 30/09/05 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 Good Practice Recommendations 100 Grosvenor Terrace G52-G02 S60231 100 GrovesnorTerrace V223766 150605 Final Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 46 Loman Street Southwark London SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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