Inspection on 15/12/05 for 10 Love Walk

This inspection was carried out on 15th December 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Love Walk 25/06/08

10 Love Walk 18/10/07

10 Love Walk 11/07/06

10 Love Walk 25/04/05

10 Love Walk 25/10/04

10 Love Walk 20/05/04

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

CARE HOME ADULTS 18-65 Love Walk, 10 London SE5 8AE Lead Inspector Ms Alison Pritchard Unannounced Inspection 15th December 2005 1:45pm DS0000007105.V254381.R01.S.doc Version 5.1 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 DS0000007105.V254381.R01.S.doc Version 5.1 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. DS0000007105.V254381.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Love Walk, 10 Address London SE5 8AE 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) 0207 703 3632 0207 252 4958 Mission Care Mr Jonathan Macy Care Home 22 Category(ies) of Physical disability (0) registration, with number of places DS0000007105.V254381.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 (twenty two) people with physical disability, some of whom may be over 65 years old. 25th April and 3rd May 2005 Date of last inspection Brief Description of the Service: 10 Love Walk is a 22 bedded care home for people with a range of physical disabilities. It is located in a quiet residential road in Camberwell. The home is situated close to local shops, public transport and services and has a small car park. The home was purpose built and each of the bedrooms is single and has a large en-suite toilet /bathing facility. There is a lift to enable residents who use wheelchairs to access the first floor. DS0000007105.V254381.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over an afternoon in mid December. The inspection methods included: discussion with approximately six residents; discussions with the Manager and care staff; discussion with a visiting professional; observation of care practices, a partial tour of the building and examination of a range of records. All but one of the core standards had been examined at the announced inspection of April 2005. This inspection focussed on assessing the home’s compliance with the requirements and recommendations. What the service does well: What has improved since the last inspection? What they could do better: The managing organisation needs to ensure that management input allocated to the home to allow the made. The Deputy Manager post is currently vacant and the senior management team, as required by Regulation, DS0000007105.V254381.R01.S.doc there is sufficient improvements to be visits by members of have not been taking Version 5.1 Page 6 place. This has meant that staff at all levels have had insufficient supervision. These issues were raised in correspondence with the Responsible Individual soon after the inspection. There are some improvements required to the systems to record medication administration and at the time of the inspection fire drills were infrequent. Some areas of the building are not homely or in a suitable decorative state. Repairs are not carried out promptly and there are a number of long standing problems which need to be addressed. 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. DS0000007105.V254381.R01.S.doc Version 5.1 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 DS0000007105.V254381.R01.S.doc Version 5.1 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, 4 The admission policy ensures that the home gathers enough information about a potential resident to make a decision about the suitability of the placement. EVIDENCE: Standards 2, 4 and 5 were assessed and found to be met at the last inspection of the home in April 2005. The file of the most recently admitted resident contained details of the person’s needs as detailed in an assessment undertaken by a social worker and in an assessment carried out by the home. Potential residents and / or their family members or representatives are given the opportunity to visit the home prior to admission. DS0000007105.V254381.R01.S.doc Version 5.1 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, 8, 9 The care planning system is under review to make sure that it reflects the full range of residents’ needs. Residents benefit from the opportunity to contribute to the running of the home at regularly held forum meetings. EVIDENCE: The arrangements for care planning were not examined in detail at this inspection as they are soon to be changed. The requirement relating to this standard remains unmet but action has been taken towards addressing the issues. A new format for care plans has been devised and staff are shortly to undertake training in its use and in the principles behind care planning. Discussion with the Registered Manager showed that it is his intention to ensure that the care plans reflect the range of needs of residents, including their social, cultural and emotional needs. It is intended that the plans will have a specific and structured method of setting goals which reflect residents’ wishes and evaluating progress towards their achievement. When the new system is implemented it will be examined fully. DS0000007105.V254381.R01.S.doc Version 5.1 Page 10 The residents have had greater opportunity participate in the running of the home in recent months as residents’ meetings are now being held each month. Minutes of a recent meeting showed that attendance is good, with the majority of residents being present at the meeting. Issues discussed included the maintenance of the building, the heating system, (see Environment below), activities, planning for Christmas and feedback about the menu. At the last inspection it was required that reviews of risk management strategies take place to ensure that residents’ rights are not restricted without adequate justification. It is intended that the new care planning system will contribute to ensuring that this is the case. A particular matter of concern relating to one resident has been resolved to the resident’s satisfaction. DS0000007105.V254381.R01.S.doc Version 5.1 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): 11, 12, 14, 16 Residents are given opportunities for skills development through the provision of appropriate equipment. They have benefited from opportunities to take part in activities in the home. Residents’ privacy is respected. EVIDENCE: A requirement of the last report related to the need to make sure that residents are provided with the correct equipment which allows them to maintain or develop independence skills. These matters have been addressed through conducting an audit of equipment and its suitability for residents, and ensuring that residents have opportunities to raise requests of this kind. Such matters will also be given greater priority through the new care planning system. There was evidence that there is a greater emphasis on the importance of activities in the home than at the last inspection. The residents’ forum meeting had been used to discuss with residents their preferences regarding activities to be arranged. On the evening of the inspection a Christmas Carol concert DS0000007105.V254381.R01.S.doc Version 5.1 Page 12 was to be held and several residents said that they were looking forward to the event. A party was planned for the week after the inspection. During November there had been a fireworks display and barbecue, a cheese and wine evening and a shopping trip. Earlier in December a quiz had been held. Residents said that this was an aspect of life in the home that they had seen improve. At the time of the last inspection it was found that some residents did not have a key to their bedroom. The Registered Manager has provided an assurance that all residents have been offered keys to their rooms. A resident informed the inspector that she is able to spend time alone whenever she wants to and that her privacy is respected. An incident was observed when a member of staff moved a resident in her wheel-chair without informing or asking the resident if this was her wish. Further management input is required to ensure that such incidents do not take place. The manager was informed of this at the time of the inspection. DS0000007105.V254381.R01.S.doc Version 5.1 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): 19, 20 Further management input is required to implement the necessary improvements to the home’s recording systems which note residents’ needs. Some improvements are needed to the systems for the management of medication. EVIDENCE: At the last inspection it was found that the recording systems needed to be improved so that tools to monitor residents’ welfare could be used more effectively. This was identified as a training need for staff and on going monitoring of the progress towards achieving this aim would be an important role for senior staff as part of their supervision of the team. The goal has not yet been fully achieved as, as noted at standard 36 below, the supervision system is not yet been implemented. Staff received training in the administration of medication in August 2005 and annual refresher course are planned. The home’s stock of medication is stored safely and safe places have been provided for residents who self-administer their medication. Some improvements are needed to the systems for the management of medication. For instance there were several unexplained gaps on the medication administration records for three residents whose records were viewed. Residents’ allergies were not recorded on the residents’ DS0000007105.V254381.R01.S.doc Version 5.1 Page 14 medication administration records. Inappropriate entries had been made on the medication administration record for an item given to a person on an ‘as needed’ basis. DS0000007105.V254381.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were examined at the last inspection of the home in April 2005. They will be subject to examination at the next inspection. DS0000007105.V254381.R01.S.doc Version 5.1 Page 16 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, 30 The premises remain in a poor condition and do not ensure that residents have a homely, comfortable and safe environment. An extensive redecoration programme is required to ensure that the conditions in the building reach the minimum standard. EVIDENCE: All of these standard were examined at the last inspection and requirements were made as a result. There have been no improvement to the system for dealing with repairs. The minutes of a recent residents’ meeting noted a considerable level of resident dissatisfaction with the number of visits made to the home by Mission Care’s maintenance team, and the resulting delays in dealing with necessary repairs. Although many of the issues raised at the last inspection of the home some remained outstanding and other matters were noted at this visit, as listed below: • • • There were holes in a bedroom ceiling The same bedroom had a badly stained carpet The wall paper in the en-suite bathroom was coming off the walls DS0000007105.V254381.R01.S.doc Version 5.1 Page 17 • • • • • A narrow alley from a fire escape was partly blocked by rubbish and needed to be cleared Fire notices in the smoking room and the ground floor corridor were detached and needed replacing A chair in the living room was broken A pelmet was detached from the window on the stairway near the main entrance Some waste bins in bathrooms were unlidded However improvements were noted in some areas of the home, in particular the hallway is now more attractive and welcoming, achieved through general tidying and the addition of a fish tank and plants. A report of a visit made by a representative of the managing organisation in May 2005 included a comment that the ‘general decorative appearance is shabby’ and stated that redecoration is planned following the appointment to the post of Manager. Now the appointment has been made the CSCI must be informed when the necessary redecoration programme is to begin. DS0000007105.V254381.R01.S.doc Version 5.1 Page 18 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, 36 Although staff support systems have improved residents would benefit further if the staff team were to receive regular supervision from senior staff in the home. EVIDENCE: The staff team are familiar with the residents and many of them have worked at the home for several years. More than 50 of the staff team have achieved NVQ level 2 or above. The need for further staff training, support and development was identified at the last inspection of the home. A requirement relating to standard 35 was within timescale at the time of the inspection and not examined. Staff meetings have been held more frequently in recent months, between June and September 2005 six meetings were held. This will improve the communication systems within the home. However staff supervision has not been taking place at the frequency stated in the National Minimum Standards (six times a year). The deputy manager post at the home remains vacant and there are no current plans to recruit to the post. This gap means that the manager is unable to provide supervision to the whole staff team and as the senior staff group are untrained in supervision issues this task cannot be delegated to them. The Registered Manager also has not received supervision from a senior manager of Mission Care. DS0000007105.V254381.R01.S.doc Version 5.1 Page 19 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, 38, 39, 42 The Registered Manager has a good understanding of the areas that need to improve in the home. Staff morale has improved and residents are positive about the developments made and planned. Monitoring of the home through visits to the home by senior managers has reduced as the visits have not been made for several months. At the time of the inspection there had not been a recent fire drill, this could have compromised the fire safety systems, this has now been addressed. EVIDENCE: The Manager has been registered under the Care Standards Act since September 2005. Staff and residents were positive about the changes that the new manager has introduced and the plans for on-going improvements. The Registered Manager will be assisted in making further improvements by additional management input which recruitment to the Deputy Manager post would allow. There were a significant number of wide ranging issues to be addressed at the last inspection of the home, and although work has begun on DS0000007105.V254381.R01.S.doc Version 5.1 Page 20 a number of the areas needing attention others remain unmet. It is important that there is sufficient management input available to address these matters. Visits to the home are not being made as required by Regulation 26 of the Care Homes Regulations 2001. The reports of visits available in the home for inspection were for May and June 2005. This matter has been the subject of requirements of inspection reports for a significant period. The health and safety records showed that there had been weekly checks of the fire alarm system and it had been serviced in early November 2005. However there were no reports of fire drills having taken place. An immediate requirement was made about this matter and the Registered Manager has since confirmed that a drill has been conducted. DS0000007105.V254381.R01.S.doc Version 5.1 Page 21 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 Standard No Score 1 x 2 3 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 x 23 x ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 x 35 x 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 x 14 3 15 x 16 2 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 2 x 3 3 2 x x 2 x DS0000007105.V254381.R01.S.doc Version 5.1 Page 22 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 YA6 Regulation 15(1) Requirement The Registered Person must ensure that care planning systems are improved by the recording of service users’ aims and goals and strategies employed by the home to support them to achieve them. The previous timescale of 01/10/05 is not met. A new date for compliance is set. The Registered Person must ensure that visits are made each month as required by Regulation 26 of the Care Homes Regulations 2001. The registered person must ensure that reports of these visits are forwarded to the home and to the Commission. The previous timescales of 01/01/05 and 01/08/05 are not not met. A new timescale for compliance is set. 3 YA7 12(4)(b) The Registered Person must ensure that further consideration is given to the range of needs which arise from residents cultural backgrounds and that this is included in care planning DS0000007105.V254381.R01.S.doc Timescale for action 01/06/06 2 YA39 26 01/04/06 01/06/06 Version 5.1 Page 23 documents. The previous timescale of 01/12/05 is not met. A new date for compliance is set. The Registered Person must ensure that staff receive management input on the purpose and value of recording systems, and that these are monitored through supervisory and other quality control systems. The previous timescale of 01/10/05 is not met. A new date for compliance is set. The Registered Person must ensure that decoration and other improvements are carried out to ensure that the home is made comfortable, homely and safe for residents. This was within timescale at the time of the inspection. The Registered Person must establish a system so that repairs are dealt with promptly. The previous timescale of 01/10/06 is not met. A new date for compliance is set. The Registered Person must ensure that effective quality assurance systems are introduced in the home. 4 YA19 18(1)(c) (i)&(2) 01/06/06 5 YA24 23(2)(d) 01/01/06 6 YA24 23(2)(b) 01/04/06 7 YA39 24 01/01/06 8 YA20 13(2) This was within timescale at the time of the inspection, it will be checked at the next inspection of the home. The Registered Person must 01/04/06 ensure that improvements are made to the systems for the recording of medication administration to ensure that the following is recorded: DS0000007105.V254381.R01.S.doc Version 5.1 Page 24 • The date/time each dose is given, and by whom, including the reason for non-administration, and the action taken. 01/04/06 9 YA30 23(2)(b) (d) 18(2) 10 YA36 The Registered Person must forward to the CSCI the plans for redecoration and refurbishment for the next year. The Registered Person must ensure that all staff are appropriately supervised. 01/04/06 DS0000007105.V254381.R01.S.doc Version 5.1 Page 25 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 2 Refer to Standard YA36 YA16 Good Practice Recommendations The Registered Person should inform the CSCI of their timescale for recruitment to the post of Deputy Manager. The Registered Person should ensure that staff who need management input regarding treating residents with respect receive such guidance. DS0000007105.V254381.R01.S.doc Version 5.1 Page 26 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. 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