Inspection on 29/03/07 for Herbert Road, 185

This inspection was carried out on 29th March 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Herbert Road, 185 29/07/08

Herbert Road, 185 04/10/07

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Herbert Road, 185 185 Herbert Road London SE18 3QE Lead Inspector Lorraine Pumford Unannounced Inspection 29th March 2007 10:00 Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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 Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Herbert Road, 185 Address 185 Herbert Road London SE18 3QE 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) TBC TBC Hillgreen Care Ltd *** Post Vacant *** Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The home is registered to provide care for three people who have been assessed as having a learning disability. The home is owned and managed by Hill Green Care. The home is an older style detached house set back from the road in a large pleasant garden. The home is within easy reach of local transport, services and shops. There is off road parking. Accommodation consists of three single bedrooms, one of which is on the ground floor. There are bath/shower rooms and toilets on both floors. Also situated on the ground floor is a lounge dining room, kitchen, utility room and office which is also used as the staff sleeping in room. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by one inspector who spent a day in the home. During that time the manager, area manager and staff on duty were spoken with. During the course of the day, residents went out to participate in activities; however, there was a brief opportunity for the inspector to talk with two residents who agreed to show the inspector their bedrooms. All three people living in the home completed CSCI surveys either individually or with the assistance of staff and their comments have been included in this report. Some policies and procedures were examined and a tour of the communal areas undertaken. The home was registered in 2006 and this was the first inspection since the home opened. The fees are currently £1,500 per week. What the service does well: A comprehensive and thorough assessment is undertaken to ensure that the home can meet residents’ needs. Residents are given the opportunity to visit the home prior to admission. Detailed care plans provide clear information for staff regarding action to be taken by them to meet the needs of the resident. Residents benefit from staff supporting and enabling them to access training, employment and a range of social activities. Staff work with residents to enable them to maintain links with family and friends and help them develop safe and appropriate relationships with their peers. Good interaction was observed between staff and residents. Residents are provided with a varied nutritional diet that reflects their cultural preferences. The home has a complaints procedure which residents understand and can access. Staff are provided with appropriate training to enable them to meet the needs of the residents accommodated. Residents are provided with a comfortable homely environment. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 6 There are sound recruitment procedures in place which protect people living in the home. There are regular resident meetings to enable residents to voice their views and opinions. 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. The summary of this inspection report can be made available in other formats on request. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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 Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff undertake a comprehensive and thorough assessment to ensure that the home can meet residents needs. Prospective residents are given the opportunity to visit the home before they are offered a place on a trial basis. EVIDENCE: Records pertaining to one resident were examined in detail in relation to the homes assessment process for prospective residents. It was apparent that staff working in the home liaised with the resident’s previous home to facilitate a smooth transition for the resident who not only has a learning disability but additional communication difficulties. In the first instance, staff working at Herbert Road had visited the prospective resident in the home he was then living, which was located in another part of the country. They had observed the resident in his own environment and ascertained information from staff that were caring for him on a day-to-day basis regarding his health, activities, demeanour and other key areas. The resident had then visited Herbert Road accompanied by staff he knew, to enable him to see his new home and meet with the other residents and staff before moving in on a trial basis. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans ensure that residents receive the care they have been assessed as requiring. Residents are encouraged to make decisions about there every day lives and risk assessments enable residents to take reasonable risks whilst enabling them to participate in everyday activities. EVIDENCE: Care plans for all three residents were seen and one residents records were tracked in detail. Care plans were very detailed and provided clear information for staff regarding action to be taken by them to meet the needs of the residents. They included such detail as residents’ preferred mode of dress, preferred time for getting up and going to bed, activities that the residents particularly enjoy etc. The care plans also included risk assessments and these enable residents to take reasonable risk whilst enabling them to participate in everyday activities Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 10 such as using the kitchen, using transport and participating in activities outside of the home. Discussion took place with the manager and area manager regarding the need for all documentation to be signed and dated by the person undertaking the assessment for updating records pertaining to residents. There was clear evidence that residents care plans are reviewed on a regular basis and include the resident and their relevant representative as well as a member of staff from the home. All residents who completed CSCI surveys stated they feel able to make decisions about what they do each day. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with activities appropriate to their age and supported to access appropriate education and training opportunities to enable them to seek paid employment. Residents enjoy a varied nutritional diet. EVIDENCE: From records seen and from discussion with staff and residents, it is apparent that staff support residents to access appropriate education and training opportunities to enable them to seek paid employment. Staff stated that this is not possible for one resident due to his high level of disability and in this instance staff have worked out a weekly schedule of activitys that meets the residents health and social needs. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 12 From discussion with staff and residents it was also apparent that they have varied opportunities to participate in appropriate social and recreational activities. Residents benefit from the provider operating their own minibus for general outings and some activities. Written information in relation to activities was limited. The manager stated she was aware of this issue and a format for recording this information was due to be implemented imminently (format seen). From records seen and discussion with staff and residents it is apparent that residents are supported to maintain links with family and friends. There was evidence that staff have worked with residents to help them develop safe and appropriate relationships with their peers. On the day of the inspection a resident was meeting with her social worker in the lounge which raises issues of confidentiality as the area was in use by other people; further, whilst the home has a telephone for residents to make and receive calls this is situated in the lounge and conversations can clearly be overheard. Discussion took place with the manager and area manager regarding the possibility of adding a conservatory which could be used by residents to make calls in private and receive guests in private without having to use communal areas if they do not wish to use their bedrooms. Staff stated that residents participating household activities depending on their individual ability. Good interaction was observed between staff and residents, who addressed residents by their preferred name. Menus seen indicate residents are provided with a varied nutritious diet which reflects their cultural preferences. Residents who are able have access to the kitchen to make refreshments as and when they wish and participate in the purchasing, preparation and cooking of meals. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff enable residents to receive the medical support they require to maintain good health. Some minor improvements to the way medication records are completed will safeguard residents and staff further. EVIDENCE: Two of the residents are able to make choices regarding clothing and personal care etc. The third person requires support and assistance from staff in relation to these issues and it was apparent staff ensure that his clothing and general appearance are appropriate for a person of his age. Care plans seen provide staff with guidance in relation to promoting residents independence so they have control over their own lives. The home operates a key worker system and staff were able to clearly demonstrate their role in relation to providing the care and support they have additional responsibility for. This was confirmed by residents who spoke highly of the staff caring for them and reaffirmed this in the CSCI surveys completed. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 14 Records seen indicated that all residents are registered with the local GP and receive support from other community health professionals as and when required. Some minor issues arose in relation to the current medication system. At present medication is supplied by a local chemist who does not supply printed MAR sheets. This means that a member of staff has the responsibility of hand writing the medication record. Discussion took place with the manager regarding the need for two members of staff to sign handwritten entries to reduce the risk of error. The manager was advised to keep a record of staff members names and the corresponding initials they use on the medication record for the purpose of auditing the medication system. The manager stated this would be addressed and further the home intended to change pharmacists to one which printed the MAR sheets in the future. All staff administering medication had attended a one-day training course and been assessed as competent to undertake the task. Medication was being safely stored. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive complaints procedure in place which residents understand and can access. Staff training in relation to adult protection helps safeguard residents. EVIDENCE: Residents are provided with information on how to make a complaint. On the day of the inspection a copy of this was also displayed in the home. Service users who completed a CSCI surveys stated they were aware of the complaints procedure and stated if they had any cause for concern they would discuss the matter with the manager or their key worker. The manager also stated that residents were encouraged to raise any concerns they may have inhouse meetings. To date the home has not received any complaints regarding the care of service provided and the CSCI have received no complaints regarding the service since it was registered in 2006. The provider arranges in-house adult protection training for all staff employed initially as part of the induction and ongoing training is arranged. Staff spoken with stated that whistleblowing was discussed at the time of their induction. Staff had a clear understanding of the term and stated they felt able Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 16 to speak to their manager or area manager if they had any concerns regarding the practice of colleagues. Staff have received formal training in relation to managing aggression from residents, which helps protect both the resident and member of staff from harm. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable and homelike environment. EVIDENCE: The premises and garden are well maintained. Communal areas are well decorated and comfortably furnished. On the day the inspection all areas of the home were clean. Residents who completed a CSCI surveys stated the home is always fresh and clean. Two of the residents showed the inspector their bedrooms. One person stated she was happy with her bedroom and liked having lots of wardrobe space; she also asked if it was possible for her to have more furniture in her room for the purpose of entertaining friends. The other resident benefits from a large ground floor bedroom. Discussion took place regarding the fact that his care plan states that in the event of the resident becoming agitated or distressed staff should support him to his Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 18 bedroom and stay with him until he becomes calm. At present the only seating in the room is one chair and discussion took place regarding the possibility of placing an additional couple of armchairs in the room to enable staff to sit with him rather than stand which could potentially create more friction. Both these issues were discussed with the manager who stated the matter would be discussed with the provider. The home has a domestic scale laundry which is accessible to residents. On the day of the inspection it was clean, organised and fit for purpose. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by an appropriately trained and qualified staff. Sound recruitment practises safeguard people living in the home. EVIDENCE: Staff stated they are encouraged to undertake training courses and are given time off in lieu for undertaking this purpose. Records seen indicate that staff were provided with a comprehensive induction period which takes place over four weeks. 50 of staff working in the home hold NVQ 2 or above qualification Staff spoken with stated that Hill Green Care provides them with appropriate training opportunities and they had not been asked to provide care to people whose needs are outside their skills or knowledge. In addition to statutory health and safety training staff have received training in relation to epilepsy, HIV and Makerton to enable them to communicate with service users who have limited verbal communication skills. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 20 Staff are provided with the General Social Care Councils code of conduct and the providers equalities policy. Records in relation to the recruitment of two members of staff were examined. These indicated that sound procedures are in place. Records indicated that references had been taken up on prospective staff, proof of identity had been checked and appropriate CRB/POVA checks had been undertaken. Residents are also involved in the recruitment process of new staff. Records also indicated that staff receive supervision on a regular basis to discuss practice, training and development. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is comprehensive health and safety policies in place, these need to be developed further to include fire protection training for staff. The provider needs to improve quality assurance mechanisms by ascertaining the views of residents, their advocates and other relevant stakeholders to find ways to improve the care and service provided. EVIDENCE: The person who has been managing the home on a day-to-day basis since last year is not registered with the CSCI and action needs to be taken to address this. From discussion with the manager and area manager it is apparent that regular audits are undertaken in relation to the care and service provided in the home each month. However, to date copies of reports written in relation to Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 22 regulation 26 visits are not being forwarded to the CSCI and action needs to be taken to address this. General discussion took place with the manager and acting manager in relation to developing quality assurance mechanisms further to ascertain the views of residents, their advocates and other relevant stakeholders. Records seen indicate that resident house meetings are undertaken. Residents who completed CSCI surveys stated care staff always listened to them and acted on what they had to say. A member of staff spoken with stated he held a first aid certificate and information provided at the time of the inspection indicates that further staff will be attending courses in the near future. Staff also stated they had received training in relation to health and safety and food hygiene. There are weekly checks to the fire alarm system and discussion took place regarding the need to arrange fire safety training for staff. Information provided at the time of the inspection indicates that safety and maintenance checks have been undertaken to the fire detection system, gas appliances and electrical wiring. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 23 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 “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 X 3 X 4 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 24 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 2 Standard YA37 YA39 Regulation CSA 2000 (11) 26 Requirement An application must be made by the manager to be registered with the CSCI. Where the registered provider is an individual but not in day-today charge of the home he shall visit the home in accordance with this regulation. The registered provider must supply a copy of the report record to be made under paragraph 4(c) to the commission. The registered person must after consultation with fire authority made arrangements for persons working in the home to receive suitable training in fire prevention. Timescale for action 31/08/07 29/06/07 3 YA42 23(4)(d) 29/06/07 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 YA12 Good Practice Recommendations Staff need to ensure they maintained a detailed record of DS0000065983.V330456.R01.S.doc Version 5.2 Page 25 Herbert Road, 185 2 3 YA20 YA20 activities undertaken by residents. Two members of staff need to sign handwritten entries on MAR sheets to reduce the risk of error. A record should be kept of staff members names and their corresponding initials used on the medication record for the purpose of auditing the medication system. Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Herbert Road, 185 DS0000065983.V330456.R01.S.doc Version 5.2 Page 27 - 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. 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