Inspection on 19/12/05 for London Mental Health Care Centre

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

London Mental Health Care Centre 24/04/09

London Mental Health Care Centre 06/05/08

London Mental Health Care Centre 01/10/07

London Mental Health Care Centre 13/11/06

London Mental Health Care Centre 09/06/05

London Mental Health Care Centre 19/05/04

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

CARE HOME ADULTS 18-65 London Mental Health Care Centre 78-80 Arran Road Catford London SE6 2NN Lead Inspector Peter Nunn Unannounced Inspection 19th December 2005 10:00 London Mental Health Care Centre DS0000025631.V271656.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 London Mental Health Care Centre DS0000025631.V271656.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. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service London Mental Health Care Centre Address 78-80 Arran Road Catford London SE6 2NN 0208 6988770 0208 6988770 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) Mr Dhaneswar Dooraree Care Home 15 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (15), of places Physical disability (1) London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 15 persons with a mental health problem, one of of whom may also have a physical disability to include four persons who may also have a learning disability - see attached sheet for details 9th June 2005 Date of last inspection Brief Description of the Service: The London Mental Health Care Centre is a care home registered to provide accommodation and care to 15 adults with mental health problems. It is situated in a quiet side road off the Bromley Road approximately 15 minutes walk from the shopping centre and civic amenities in Catford. The home has 13 single rooms, and one shared room. There is a communal area for dining, and an activities area where there is a television and a pool table. There is a goodsized garden with patio area with outside seating. There is also a quiet room for private meetings of staff and service users. The home has a well-qualified staff team and service users have effective rehabilitative care programmes to enable them to move on to more independent living situations where possible. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over half a day in December. The inspection included speaking with service users, the deputy manager and other staff and examining care plans, staff records and other records. Evidence suggested that this home is well managed and provides a good level of support to service users. The focus of this inspection was therefore on compliance with previous requirements and the core standards. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 6 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 London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 7 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): None None of these standards were assessed. At the last inspection the following judgement was made :Service users’ needs are assessed prior to admission to ensure that the home is able to meet them. Each service user has a contract or statement of terms and conditions, which ensures that their rights are protected. EVIDENCE: London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 8 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): 6,8 Service user needs are clearly reflected within care plans. Service users are consulted on life within the home although this area could be improved by the formalisation of keywork sessions. EVIDENCE: Four service user files were seen at this inspection. All had a comprehensive care plan in place. The care plans covered all of the areas required in the National Minimum Standards. Activities the service user had taken part in and day-to-day progress were also recorded and were now also being recorded on a daily basis as previously required. This helps the home to evidence how, on a daily basis, the home is meeting service users needs or working with them to achieve their goals. All service user files examined contained a brief risk assessment and fuller risk assessments provided by the service user’s mental health teams. Where risks have been identified these are addressed in the service user’s care plan and are regularly reviewed. The service user files contained evidence of keywork sessions, but these appeared sporadic in nature with no clear policy for their use. Keywork session London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 9 would form an important opportunity for service users to be consulted on the home and should be formalised. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Service user rights and responsibilities are respected and changes in the visitors policy and the location of the phone now means that service users are better able to conduct relationships. EVIDENCE: Following the previous inspection, the home has updated the visitor policy to ensure that it was clear to all the people who use the service when people could visit and under what circumstances the home would need to be notified in advance of a service user wishing to receive visitors. The home had ensured that all service users were aware of the new policy by asking each resident to sign the policy once that had read the policy and understood it’s contents. Service users spoken to by the inspector confirmed the contents of the new policy and stated that they were happy with the new arrangements. The telephone in the communal lounge has now been screened off to enable service users to make and receive telephone calls in private. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None All of these core standards were assessed at the last inspection and deemed met and were therefore not inspected on this occasion. The judgement made at the last inspection was :Service users confirmed that they receive the personal support that they need. Service users physical and mental healthcare needs are met and medication policies and procedures are safe. EVIDENCE: London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users are confident their complaints will be listened to; however, further work needs to be done to ensure there is evidence that these complaints have been acted upon. Service users are protected from abuse, neglect and self harm by the presence of appropriate procedures and staff who have received training in recognising and dealing with abuse. EVIDENCE: The complaints book evidenced that the home were proactive in dealing with complaints from service users. The complaints procedure includes a statement that service users will not be victimised for making a complaint and from speaking to service users it is apparent that service users have every confidence in this statement. Four complaints had been recorded since the last inspection and all had been recorded appropriately. The majority were minor complaints and had been responded to appropriately. However, two complaints had been recorded where it was not clear what action had been taken by the home to resolve the complaint and this must be included in future. The home has an appropriate adult protection policy and procedure. The procedure is clearly linked to the local authority’s adult protection procedure and had been reviewed in May 2005. Four staff have received training in adult protection during 2005. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 13 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): 24,27,28,30 The home is homely, comfortable and safe with sufficient toilets and bathrooms for the service users. Shared space is adequate and the home was found to be clean and hygienic. EVIDENCE: The home is situated in a quiet side road off the Bromley Road approximately 15 minutes walk from the shopping centre and civic amenities in Catford. The home has 13 single rooms and one double room. There are two toilets and a bathroom on the ground floor and one bathroom, one shower room and three toilets on the first floor. The home has a large pleasant garden with a patio and seating area. There is a communal area with separate areas for dining and activities including a pool table and TV. There are two smoking rooms, one on the ground floor and one on the first floor. On the day of the inspection the home was clean throughout. The home has a laundry area that is away from areas where food is prepared and eaten. There is an industrial washing machine that has a sluicing facility and a tumble dryer. Hand washing facilities were also sited in this room. The home has appropriate policies in place for control of infection. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 14 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, 34, 35 Service users are supported by competent and qualified staff and are protected by the home’s recruitment practises. Their individual and joint needs are met by appropriately trained and inducted staff. EVIDENCE: Staff files were examined and each had two written references in place. All files examined also had a disclosure from the criminal records bureau (CRB) at the appropriate level as required by the previous inspection. The home has clearly improved on its recruitment processes with evidence on staff files of photographs, evidence of identity checks, job descriptions, copies of the original application forms and the questions asked at interview. Training records were available in each staff file and also copies of certificates of training attended prior to staff’s employment at the home. The home has a well-trained staff team with four qualified nurses excluding the manager. One of the staff files inspected was for a new member of staff. There was evidence on the file of a foundation workbook that was linked to TOPSS, which was clearly being worked through with the staff member concerned. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Service users benefit from a well run home and are confident that their views underpin all self-monitoring, review and development by the home. Generally the health, safety and welfare of service users are promoted and protected although one certificate had recently lapsed. EVIDENCE: The registered provider is also the registered manager for the home. He is an experienced Registered Mental. He has managed mental health care homes for many years and has managed the London Mental Health Care Centre since he opened it six years ago. Policies and procedures are regularly reviewed. Requirements identified at inspections are implemented within agreed timescales. The home has monthly service users meetings on a Sunday, the minutes of which were seen. These meetings were clearly being used by service users as an opportunity to raise and discuss issues about the home and were well attended. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 16 In addition, there are a number of checklists that are monitored by the manager or senior staff on a regular basis to ensure that tasks are being performed correctly. These include a check on care plans and documentation in service users’ and staff files. Records indicated that all fire and gas systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. Environmental health and fire inspections had also been conducted in the recent past and no concerns were identified. However, the certificate regarding the electrical installation, which had been completed in November 2002 recommended re-inspection within two years and is now due. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 London Mental Health Care Centre Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000025631.V271656.R01.S.doc Version 5.0 Page 18 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 YA22 Regulation 22 (3)&(4) Requirement The registered manager must ensure that the complaints record includes details of action taken by the home to resolve a complaint The registered manager must ensure that the electrical wiring installation is inspected by a person qualified to do so. Timescale for action 31/03/06 2. YA42 23(2)(b) 31/01/06 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 YA8 Good Practice Recommendations The registered manager should consider formalising keywork sessions so that they occur at regular intervals and have a set structure that is shared with service users. London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 19 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 London Mental Health Care Centre DS0000025631.V271656.R01.S.doc Version 5.0 Page 20 - 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. 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