Inspection on 05/05/05 for Grove Road (107-109)

This inspection was carried out on 5th May 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 no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grove Road (107-109) 24/05/07

Grove Road (107-109) 08/12/06

Grove Road (107-109) 25/04/06

Grove Road (107-109) 18/10/05

Grove Road (107-109) 05/01/05

Grove Road (107-109) 04/08/04

Grove Road (107-109) 16/02/04

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

CARE HOME ADULTS 18-65 Grove Road (107-109) 107-109 Grove Road Walthamstow London E17 9BU Lead Inspector Rob Cole Announced Inspection 5th May 2005 10:00am 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. Grove Road (107-109) Version 1.10 Page 3 SERVICE INFORMATION Name of service Grove Road (107-109) Address 107-109 Grove Road, Walthamstow, London E17 9BU 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 8520 6435 Mrs Conchita Damaguen Pooten Mrs Conchita Damaguen Pooten Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Grove Road (107-109) Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th January 2005 Brief Description of the Service: The home is registered to provide accommodation and support to nine service users with mental health needs. It consists of three homes that have been converted into one. The home is situated in a residential area of Walthamstow in the London Borough of Waltham Forest, and is close to shops and other local amenities, including transport networks. The home is indistinguishable from other homes in the area. The home is privately run. Grove Road (107-109) Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 5/5/05 and was announced. The inspector had the opportunity of speaking with the homes manager, service users and staff. Service users spoken to informed the inspector that they are happy with the level of support they receive at the home, and improvements have been made since the last inspection. However, there is still room for improvements, and sixteen requirements have been set during this inspection. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or Grove Road (107-109) Version 1.10 Page 6 by contacting your local CSCI office. Grove Road (107-109) Version 1.10 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 Grove Road (107-109) Version 1.10 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) 1,3,4 and 5 Although service users have the opportunity of visiting the home before making a decision as to move in or not, the inspector believes the home could do more to help service users make an informed choice. For instance more written information needs to be provided about the home, and placements must be reviewed after an initial period. EVIDENCE: The home has both a Statement of Purpose and Service User Guide in place, both documents are written in plain English, and are accessible to service users. The Statement has been updated since the last inspection, and now includes all information required by the Care Homes Regulations 2001, including details of the organisation and the aims and objectives of the home. However, the Guide is not in line with the Requirements and National Minimum Standards, for example it does not include information on what the fees are, what they cover and what is extra. This must be addressed. All service users have a written contract/statement of terms and conditions, these have been updated since the last inspection and now contain all required information. These have been signed by the manager and service users. The home has an admissions procedure which covered both planned and emergency admissions. The procedure stated that service users would be given the opportunity to visit the home before making a decision as to move in or Grove Road (107-109) Version 1.10 Page 9 not, and service users spoken to confirmed that this was indeed the case. The procedure also stated that service users would initially move into the home on a trial basis, after which a placement review meeting would be held, attended by the service user, family, house manager, social worker and consultant psychiatrist. However, for the most recent admission to the home there was no evidence that such a review had ever taken place, and it is required that service users are admitted to the home in line with its admissions procedures. Grove Road (107-109) Version 1.10 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 and 10 The inspector was satisfied that service users have control over their daily lives and are involved in the day to day running of the home. However, the home must ensure that service users safety is not been put at risk by lack of attention to risk assessments. EVIDENCE: Service users have individual care plans in place, and since the last inspection there is evidence that these are now regularly reviewed. Plans are drawn up with the involvement of the service user and the homes manager. Care plans include medical and mental health needs and social and leisure needs. The manager informed the inspector that all service users are also on the Care Programme Approach plan, with yearly reviews. However, there was no evidence of any minutes of these meetings, and it is required that these are in place within the home, and that service users have access to them. Service users have risk assessments in place, and these have been reviewed and considerably improved since the last inspection. However, they still need further development, for example one risk assessments highlights that a service user is at very high risk from malnutrition, yet gives no indication of how this risk can be managed and reduced. Grove Road (107-109) Version 1.10 Page 11 Through observation and discussion there was evidence that service users have control over their daily lives. Service users were able to get up and go to bed as they choose, and were free to come and go from the house, and have their own front door keys. One service user has restrictions in place on tobacco, in that the home keeps their tobacco on their behalf and they are given a daily allowance. The reasons for this are clearly recorded, and the service user confirmed to the inspector that they were in full agreement with this procedure. Service users are regularly consulted over the running of the home, for example they were involved in choosing the new carpets which the home recently had fitted, and regular service user meetings are held. Confidentiality is respected, the home has a clear policy on confidentiality, and records are stored securely. Grove Road (107-109) Version 1.10 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 and 17 The inspector was impressed by the degree of choice and freedom service users have over their lifestyle, and the number of educational, employment and leisure opportunities that are available to them. EVIDENCE: There was evidence that service users have appropriate access to leisure, educational and employment opportunities. Several service users are involved in employment, for example one works at a local shop, another in a café. Service users are also involved in educational programmes, attending local colleges, one service user is on a food hygiene course, while another is on an IT course, and is planning on buying their own computer. The home has made efforts to meet service users individual cultural needs, for instance through food and religion. Indeed, the home comprises of service users from many differing religions, and attempts have been made to meet all their needs, one service user regularly attends a local mosque, others attend various churches and an evangelical church group visits the home twice a week. Service users are involved in a variety of social and leisure activities, both in house and in the community. In house service users have access to TV, video, music, BBQ’ Grove Road (107-109) Version 1.10 Page 13 and the home holds parties to celebrate birthdays and religious and cultural festivals. In the community service users visit local parks, restaurants, cafes and the cinema, while one service user likes to go fishing. Service users have an annual holiday, which they help to choose and plan, and are planning on a holiday in Wales later this year. Service users have access to amenities within the community, such as local transport networks, shops and banks, and on the day of inspection six service users went to vote in the general election being held on that day. Service users are able to plan their own menus, and records are kept of menus. These indicated that service users eat a healthy, balanced and nutritious diet. Service users cultural needs are met through food, for example one service user is able to buy only Halal meat. Service users were observed to help themselves to drinks and snacks throughout the day. Grove Road (107-109) Version 1.10 Page 14 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) The inspector believes that despite improvements the home is not yet fully meeting the healthcare needs of service users. Medication procedures need to be tightened up, and service users must have access to health professionals as appropriate. EVIDENCE: All service users are registered with a local GP. Service users also have access to other health professionals, including psychiatrists, CPN’s, dietician and chiropodists. However, at the last inspection it was noted that service users have not had regular access to dental care, and this was found to be still the case at this inspection, and it is required that service users have access to healthcare as appropriate. Since the last inspection the home now records service users medical appointments. This recording is very basic, and needs to be updated to include the outcomes of appointments, and record any follow up action necessary. The home has made improvements with regard to medication since the last inspection. It now has a medication policy in place, all medications were stored securely and staff receive training before they are able to administer medication. Despite these improvements, there were still some areas of concern. There were no guidelines in place for the administration of medications prescribed on an as required basis, and medications were kept in dossette boxes, but these boxes did not have labels on stating what medication they contained. Grove Road (107-109) Version 1.10 Page 15 Service users are able to manage their own personal care, although the home will give encouragement and advice on clothing appropriate for the weather. The manager informed the inspector that service users would be able to remain in the home with a terminal illness, so long as the home could meet their medical needs. Grove Road (107-109) Version 1.10 Page 16 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 and 23 The inspector was satisfied that sufficient measures have been taken to enable service users and others to make a complaint, and for those complaints to be appropriately dealt with. However, to help ensure that service users are safe with regard to adult protection issues, the home must ensure that its policy is in line with current legislation. EVIDENCE: The home has a clear complaints procedure. This was prominently displayed within the home, and included timescales for responding to any complaints. The procedure has been updated since the last inspection, and now includes contact details of the CSCI. Service users spoken to showed a good understanding of whom they could complain to if they so wished. The home also maintains a complaints log, although the manager informed the inspector that no complaints have been received in the past year. The home has a copy of the Local Authorities adult protection procedures, and since the last inspection it now has its own policies in place on adult protection. However, this is not in line with current legislation, for example it does not make clear the homes responsibilities to inform the Local Authority and the CSCI of any suspected instances of abuse. Since the last inspection all staff have now received training in adult protection issues. All service users are able to manage their own finances, and the home does not keep money on behalf of service users. Grove Road (107-109) Version 1.10 Page 17 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) 24,25,26,26,28 and 30 The inspector is satisfied that the home is suitable to meet its stated purpose. Service users have their own bedrooms, and communal areas and bathrooms and toilets are adequate to meet service users needs. EVIDENCE: The home consists of three houses converted into one, and is situated in the Walthamstow area of the London Borough of Waltham Forest. The home is in keeping with other homes in the vicinity, close to shops, transport links and other local amenities. All service users have their own bedrooms, five of these are ensuite and the others all have hand basins fitted. All bedrooms had adequate natural light and ventilation, and bedding, carpets and curtains were well maintained. Service users have been able to personalise their rooms, for example with family photographs, and bedrooms meet National Minimum Standards on size requirements. In addition to the five ensuite bedrooms, the home has one toilet/shower room, one toilet bathroom and one toilet on its own. Bathrooms were clean, tidy and free from offensive odours. However, a lock with an emergency override device must be fitted to the downstairs shower room. Grove Road (107-109) Version 1.10 Page 18 The communal areas consists of three lounges, (one a designated smoking room), two kitchen/dining areas and a garden with appropriate garden furniture. Furniture and fittings around the home were generally well maintained and domestic in character. The home has recently had new carpets fitted, which service users helped to choose. The home has suitable measures in place to help prevent the spread of infection, for example protective clothing is available to staff, and COSHH products were stored securely. Grove Road (107-109) Version 1.10 Page 19 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) 31,32,33,34,35 and 36 Staff appear to be competent to carry out their duties, and have built up good relationships with service users. However, the inspector believes that staff would further benefit from regular formal supervision, and the home must ensure that it follows appropriate recruitment procedures for recruiting new staff to the home. EVIDENCE: The home provides 24-hour support, including an emergency on-call system. On the day of inspection there was a staff rota, which accurately reflected the staffing situation. The inspector was satisfied that staffing levels are adequate to meet service users needs. All staff are given a copy of their job description, and through observation and discussion staff were able to demonstrate a good understanding of their roles and responsibilities. However, staff have not yet received a copy of the General Social Care Council codes of conduct and this is a repeat requirement. The home has policies in place on equal opportunities and recruitment and selection. There has been no new staff recruitment to the home since the last inspection, therefore requirements set at the previous inspection remain outstanding and are repeated in this report. All staff receive a structured induction on commencing work at the home, this includes health and safety and service user issues. Staff have recently received Grove Road (107-109) Version 1.10 Page 20 training in medication, fire safety, food hygiene, adult protection and since the last inspection all staff have undergone training in working with adults with mental health needs. Of the six care staff employed at the home, the inspector was informed by the manager that five either have or are currently working towards relevant NVQ’s. Staff spoken to informed the inspector that they receive regular on-going informal supervision from the manager, but as yet no staff receive any formal supervision. It is required that all staff receive formal supervision at least six times a year, and that records are maintained of this supervision, and the staff receive their own copy of the minutes. Grove Road (107-109) Version 1.10 Page 21 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) 37,38,39,40,41,42 and 43 The inspector was satisfied that the homes manager is suitably qualified and experienced to carry out their duties. EVIDENCE: The homes manager is a Registered Mental Health Nurse, with thirty years experience of working with adults with mental health, including twenty years in a managerial capacity. Staff and service users spoken to informed the inspector that they found the manager to be approachable and accessible, and on the day of inspection staff were observed to interact with the manager in a relaxed manner. The home has various systems in place to promote quality assurance, for example staff meetings, service user meetings and care plan reviews all contribute to the quality assurance within the home. Questionnaires are given to service users and visitors to gain their feedback on the home, and those seen by the inspector were generally positive. Improvements have been made in the homes documentation, at the last inspection several policies and minutes of meetings were either not in place or could not be located on the Grove Road (107-109) Version 1.10 Page 22 day, at this inspection the home appeared to have all necessary documentation in place. This was stored securely, and service users and staff can access confidential records as appropriate. Various routine health and safety checks are carried out, for example/fridge freezer temperatures are recorded, and since the last inspection the home now holds regular fire drills. However, the home still does not test all hot water outlets used for personal care, and it is a repeat requirement that this is done. Fire fighting equipment was situated throughout the home, and the home tests its fire alarms on a weekly basis. Both the alarms and the fire fighting equipment have recently been serviced by an engineer. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x 2 2 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 Grove Road (107-109) Score 2 Standard No 24 25 26 27 28 Version 1.10 Score 3 3 3 2 3 Page 23 7 8 9 10 LIFESTYLES 3 3 2 3 Score 29 30 STAFFING x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 3 3 1 3 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 3 Grove Road (107-109) Version 1.10 Page 24 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 YA9 Regulation 13 Requirement The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to service users and others. (timescale 30/4/05 not met) The registered person must ensure that all service users are registered with a dentist and offered dental care as appropriate. (timescale 30/4/05 not met) The registered person must ensure that records are maintained of all medical appointments, and any follow up action required. (timescale 30/4/05 not met) The registered person must ensure that all staff working in the home are provided with a copy of the General Social Care Council codes of conduct. (timescale 30/4/05 not met) The registered person must ensure that all staff receive satisfactory CRB checks prior to their commencing work in the home. (timescale 30/4/05 not met) Version 1.10 Timescale for action 31/8/05 2. YA19 13 31/8/05 3. YA19 13 31/8/05 4. YA31 18 31/8/05 5. YA34 19 31/8/05 Grove Road (107-109) Page 25 6. YA34 19 7. YA34 18 8. YA42 13 9. YA23 13 10. YA1 5 11. YA4 14 12. YA6 15 13. YA20 13 14. YA20 13 The registered person must ensure that they obtain all information listed in Schedule 2 of the Care Homes Regulations 2001 for all staff working in the home. (timescale 30/4/05 not met) The registered person must ensure that the home follows its recruitment procedures when recruiting staff to the home. (timescale 30/4/05 not met) The registered person must ensure that all water temperatures used for personal care are checked weekly, and ensure that temperatures do not exceed 43 degrees centigrade. (timescale 30/4/05 not met) The registered person must ensure that the home has a policy in place on adult protection which is in line with current legislation. (timescale 30/4/05 not met) The registered person must ensure that the homes Service User Guide contains all information required by National Minimum Standard 1. The registered person must ensure that all service users are admitted to the home in line with the homes admission procedures. The registered person must ensure that the home recieves copies of the minutes of all CPA meetings, and that service users have access to these minutes. The registered nperson must ensure that clear guidelines are in place on the administration of medications prescribed on an as required basis. The registered person must ensure that all containers used to store sevice users medication Version 1.10 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 Grove Road (107-109) Page 26 15. YA27 23 16. YA36 18 clearly state what that medication is. The registered person must ensure that all toilets and bathrooms are fitted with a lock, with an emergency overide device. The registered person must ensure that all staff recive regular formal supervision at least six times a year, and that records are kept of supervsions, and staff receieve a copy of the minutes. 31/8/05 31/8/05 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 YA8 Good Practice Recommendations It is recommended that service users are given the opportunity to participate in the recruitment of all staff to the home. Grove Road (107-109) Version 1.10 Page 27 Commission for Social Care Inspection 4th Floor, Gredley House 1-11 Broadway, Stratford London E15 4BQ 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 Grove Road (107-109) Version 1.10 Page 28 - 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. 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