Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 18/10/05 for Grosvenor Terrace, 100

Also see our care home review for Grosvenor Terrace, 100 for more information

This inspection was carried out on 18th October 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 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

The laundry facilities have been separated from the kitchen area and the recording of medication storage and administration is more consistent and effective.

What the care home could do better:

CARE HOME ADULTS 18-65 Grosvenor Terrace, 100 100 Grosvenor Terrace London SE5 ONL Lead Inspector Lisa Wilde Unannounced Inspection 18th October 2005 10:00 Grosvenor Terrace, 100 DS0000060231.V257489.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 Grosvenor Terrace, 100 DS0000060231.V257489.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. Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grosvenor Terrace, 100 Address 100 Grosvenor Terrace London SE5 ONL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7701 5622 Odyssey Care Solutions for Today Ms Celia Denise Bownass Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2005 Brief Description of the Service: The provider of this home is Odyssey Care Solutions for Today. 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” Grosvenor Terrace, 100 DS0000060231.V257489.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 one day in October 2005. The Registered Manager was way from the home on training and the inspection took place with staff and service users. The inspector contacted some family members by telephone following the inspection day. The family members contacted said that they were very happy with this “lovely, spotless” home. They said staff keep them informed of what is going on with their family members and that they know who to go to should they have any concerns. They said they are always made welcome when they want to visit and staff are very friendly. The inspector found again that a high standard of care continues to be provided to these service users by a knowledgeable and committed staff team. There were some requirements from the previous inspection that had not been met and these will need to be addressed by the next inspection, particularly informing the Commission of the outcome of a staffing review to enable service users to be escorted out of the home more frequently. What the service does well: Of the standards assessed at this inspection the home showed that: • a prospective service users’ needs would be effectively assessed before they move into the home. • service users needs and how to meet them are reflected in their individual care plans. • as far as possible service users are included in decisions about their lives. • risks are assessed effectively and plans put in place to manage or minimise those risks. • generally service users are supported to access the community and undertake a varied and appropriate activities programme throughout the week. (There is an ongoing unresolved issue about increasing staffing to enable service users to be supported out of the house more often). • service users are offered a healthy diet and as far as is possible to judge, they enjoy their food. • generally the home records the storage and administration of medication effectively (apart from p.r.n medication). • 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 • the home is clean, homely and attractive throughout. • the health, safety and welfare of service users are being protected by the effective use of procedures and regular monitoring at the home. Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Grosvenor Terrace, 100 DS0000060231.V257489.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 Grosvenor Terrace, 100 DS0000060231.V257489.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): 2 There have been no admissions to this home for many years so the current procedures for assessing prospective service users aspirations and needs have not been used recently. Given discussions with staff and the evidence from the files around assessment of needs of current service users there is no reason to believe that the home would not fully assess a prospective service users’ needs prior to making the decision whether to accept them into the home. EVIDENCE: All the current service users have been at this home for a long time and as there have been no admissions there has been no need for pre-admission assessments. The files showed that full assessments of current needs take place and are reviewed at least annually. Discussions with staff evidenced that they have a comprehensive knowledge of service users needs and how to meet them as a team. Grosvenor Terrace, 100 DS0000060231.V257489.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 & 9 Service users needs and how to meet them are reflected in their individual care plans. As far as possible service users are included in decisions about their lives. Given the communication limits of the service users at this home, family members and independent advocates are included in the decision making process. Risks are assessed effectively and plans put in place to manage or minimise those risks. EVIDENCE: The files showed that all service users have in place detailed support guidelines and programmes in place. The service users at this home are non-verbal and have limited communication abilities. Staff hold a comprehensive knowledge of the service users, as they have known them for many years. The talked about how they are able to understand the behaviour of the service users and assess their moods and wishes as far as possible. The home access independent advocates for service users in their reviews and family are involved as much as possible. One family Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 10 member said that they are kept informed of things that happen to their relative by staff on an ongoing basis. Risk assessments were on file for service users with actions to be taken to manage or minimise identified risks. Grosvenor Terrace, 100 DS0000060231.V257489.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 & 17 Generally service users are supported to access the community and undertake a varied and appropriate activities programme throughout the week. There is an ongoing unresolved issue about increasing staffing to enable service users to be supported out of the house more often. Service users are offered a healthy diet and as far as is possible to judge, they enjoy their food. EVIDENCE: Discussions with staff and evidence from the files showed that service users are offered a variety of activities within and outside of the home. Day centres are used and service users are part of the local community. There had been an issue at the last inspection where the Registered Manager had stated that she did not believe the home had enough staff to enable service users to access the community as much as they should and had made a proposal to the organisation to increase staffing. During this inspection staff commented that there are sometimes difficulties ensuring that there are enough staff in the building with service users who are at home and escorting service users out on activities. The requirement around this issue had previously been made under Standard 33. Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 12 The menus showed that service users are offered a varied and healthy diet. As the service users are non-verbal it is more difficult to assess what they want but staff said that they show service users different options and enable them to make certain choices. Grosvenor Terrace, 100 DS0000060231.V257489.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): 20 Given the different abilities of people at this home it is not possible for service users to self-medicate. Generally the home records the storage and administration of medication effectively, apart from p.r.n medication. Staff need further training in one area of administration. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that a review takes place of the use of the helmet for one service user, involving all members of the care team with an additional Epilepsy Nurse. Staff stated that this had not as yet happened, as they had not been able to access an Epilepsy Nurse. Any epilepsy specialist would be appropriate. (See Requirement 1) There were several previous requirements around medication administration and recording all of which had been met by this inspection except that staff have not as yet been trained in the administration of rectal diazepam and a district nurse has been used to administer this in the interim. (See Requirement 2) There were no gaps in recording and all stock checks tallied with the records. Some medication was in a paper bag with no labels and there was no administration sheet for one prn medication. (See Requirements 3 & 4) Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 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 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: There was a previous requirement that the Registered Manager must ensure that the correct contact details for CSCI, along with a brief explanation of their purpose, is included in the Complaints Policy and Procedure and Service User Guide. The details in the Complaints Policy in the hallway had been altered by hand but the organisational policy and the Service User Guide had not been changed and the requirement is repeated. (See Requirement 5) Family members said that they knew who to go to if they had a concern about something at the home. Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 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. On the day of the inspection the home was clean and hygienic throughout. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the planned laundry refurbishment is carried out as a priority and this had been done by this inspection. 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. There were still some ongoing maintenance issues; fixing the broken staff shower and replacing cupboard doors in the kitchen, which must be met. The staff said again that since the handover of this service from Southwark Social Services to Odyssey last year they have been having problems getting maintenance issues dealt with quickly. There was a previous requirement that 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. It was not possible to evidence that this requirement had been met. (See Requirement 6) Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 16 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. Grosvenor Terrace, 100 DS0000060231.V257489.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): 32, 33 & 35 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: Thje home is achieveing the target opf 50 of care being provieded by staff who hoel the NVQ Levelk 2 in Care or equivalent. Staff said that generally training within the organisation is effective and useful although occassionally there are courses that do not meet their needs as much as some staff at other homes given the length of time they have been working with these service users. There was a previous requirement that 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. The Commission had not yet been informed of the outcome of the review and the requirement is repeated (See Requirement 7) The inspector will be assessing all the organisation’s recruitment records at a later date this year at the head office. Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 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 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): 39 &42 Although the organisation does undertake reviews of care and includes the goals of service users in their development plans for the home, the home does not ensure that service users views (or the views of their families) underpin the review and development of the home. The health, safety and welfare of service users are being protected by the effective use of procedures and regular monitoring at the home. EVIDENCE: The monthly inspections by the Responsible Individual take place as required. The home conducts annual reviews with the service users and completes quarterly returns to the borough organisation that report on identified indicators. There is a local business plan for the home. The home does not use an externally accredited quality assurance systems that focuses on the views of service users and the home does not conduct an annual review of the views of family and other stakeholders. From inspections of other Odyssey homes the inspector had been made aware that the organisation is currently planning an Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 19 organisational procedure for gathering the views of families and other parties. (See Requirement 8 and Recommendation 1) No health and safety issues were found on the tour of the building and all the required checks and monitoring is taking place. Health and safety systems are being operated effectively. The laundry has now been moved to the designated area separate from the kitchen. Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 20 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 3 X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grosvenor Terrace, 100 Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000060231.V257489.R01.S.doc Version 5.0 Page 21 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 YA19 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, involving all members of the care team with an additional Epilepsy Nurse or epilepsy specialist. Previous requirement: Unmet timescale 30/09/05 The Registered Manager must ensure that all staff attend training in the administration of rectal diazepam. Previous requirement: Unmet timescale 30/09/05 The Registered Manager must ensure that all medication is recived into the home in correctly labelled packaging. The Registered Mangaer must ensure that all p.r.n. medication is recorded on the same type of medication administration charts as regular medication. The Registered Manager must ensure that the correct contact details for CSCI, along with a brief explanation of their purpose, is included in the Complaints Policy and Procedure DS0000060231.V257489.R01.S.doc Timescale for action 31/01/06 2 YA20 13 (2) & 31/01/06 3 YA20 13 (2) & 21/11/05 4 YA20 13 (2) & 21/11/05 5 YA22 22 (7) 31/01/06 Grosvenor Terrace, 100 Version 5.0 Page 22 6 YA24 23 (2) (b) & (d) 7 YA33 18 (1) (a) 8 YA39 12 (3) and Service User Guide. Previous requirement: Unmet timescale 370/09/05 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. Previous requirement: Unmet timescale 30/09/05 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. Previous requirement: Unmet timescale 30/09/05 The Registered Manager must ensure that an annual survey (or other form of annual audit) of service users families and other stakeholders takes place that then feeds into the annual review of the service and the local business plan. 31/01/06 31/01/06 31/03/06 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 YA39 Good Practice Recommendations The Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grosvenor Terrace, 100 DS0000060231.V257489.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!