Inspection on 19/12/05 for Chalton Street

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 Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chalton Street 22/06/06

Chalton Street 23/08/05

Chalton Street 13/12/04

Chalton Street 10/06/04

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

CARE HOME ADULTS 18-65 Mary Wollstonecraft House 99 Chalton Street London NW1 1SP Lead Inspector Ms Pippa Treadwell-Smith Unannounced Inspection 19th December 2005 13:00 Mary Wollstonecraft House DS0000010325.V273677.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 Mary Wollstonecraft House DS0000010325.V273677.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. Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mary Wollstonecraft House Address 99 Chalton Street London NW1 1SP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7388 4137 020 7388 4137 Umbrella Ms Joann Superville Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. For the provision of Mental Health Nursing Care for up to 9 adults, who are not required to be detained at the home under any section of the Mental Health Act The staffing notice Date of last inspection Brief Description of the Service: Mary Wollstonecraft House is a purpose built care home, which offers a nursing service for up to nine people with mental health needs. The registration of the home enables it to take service users from the age of 18 years up to 65 years. The home offers support with personal care, cooking, cleaning, shopping and claiming benefits. As the home is registered to provide nursing care, then a registered mental health nurse is available on shift over a twenty-four hour period. The building is owned and maintained by St Pancras and Humanist Housing association. The service is operated by Umbrella, which is a mental health charity providing a full range of care and support services in North London. The home is sited within a residential area. Information about the home states that it is five minutes walk either from Euston Station or Mornington Crescent. It is also on several bus routes including the 253 between Hackney and Euston Station and passes via Eversholt Street and Camden High Street. The number 168 bus, Hampstead Heath and Waterloo passes Eversholt Street, Euston Station and Camden High Street. The house has been designed over three floors. There is level access to the main entrance and the interior of the home is wheelchair accessible. A walled patio garden is at the rear of the property. Access to the garden is via french windows allowing egress by service users in wheelchairs. All the bedrooms are single occupancy with wash hand basins. A shaft lift ensures access to the upper floors. Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one afternoon in December 2005 and lasted about four hours. The manager was available and assisted with the inspection; the focus of which was to assess the remaining key standards that had not been looked at during the previous visit. The inspector had the opportunity to talk to the manager and have general discussion with the service users and some of the staff. A variety of records were looked at including care plans, training records and health and safety documents. What the service does well: What has improved since the last inspection? What they could do better: The home met all the standards, which were assessed during this visit. Please contact the provider for advice of actions taken in response to this Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not assessed EVIDENCE: Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7 Service users are supported to independent and to make informed choices and decisions. EVIDENCE: The policy of Umbrella is to encourage and facilitate maximum independence for service users. The care records show that service users have made decisions regarding who will have access to their personal information, resuscitation and active treatment, contributed ideas in house meetings and been engaged in developing their individual activity plans. There are risk management plans for service users who have been assessed as competent to self–medicate. Risk assessments are available to support other activities. Mary Wollstonecraft House DS0000010325.V273677.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): Standard 13 & 16 Service users participate in community activities in a planned and focused way giving them a sense of purpose and achievement. Staff support service users to be as independent as possible. EVIDENCE: The minutes of the house meetings show that service users have made suggestions about community activities and these have been followed through. On the day of the inspection a service users was planning an excursion to see the Christmas tree in Trafalgar Square. There is information available for service users about local activities, support and resources that are offered in the neighbourhood. Key workers discuss with service users opportunities for social activities and engagement that they may prefer. Staff were observed being fully engaged with the service users. Service users have access to all the communal parts of the home. Their right to privacy is respected. Staff knock on bedrooms doors and wait to be invited in to rooms. Preferred forms of address as well as likes and dislikes are recorded and known to staff. Service users are engaged in deciding what they need in order to move on. Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 11 Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 12 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): Standard 20 The systems for medication are satisfactory with clear arrangements in place to ensure that service users’ medication needs are met. EVIDENCE: Medication is administered by nursing staff. There is a policy and procedure available that meets with the Nursing and Midwifery Council Guidelines. It includes a procedure to follow in case on non-compliance. It will be recommended that this procedure is extended to include notifying the CSCI under Regulation 37 of The Care Homes Regulations 2001. The home has a Pharmacy Contract Agreement and receives advice and routine inspections from the Community Pharmacist. The CSCI will also try to arrange a full inspection from one of their designated Pharmacy Inspectors. The MARS sheets were looked at and found to be accurate and up-to-date. Weekly audits are carried which includes checking stock levels. The manager confirmed that the home is still in consultation about the disposal of medication according to the revised legislation affecting nursing homes. Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 13 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): These standard were not assessed EVIDENCE: Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 14 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): These standards were not assessed EVIDENCE: Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 15 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 Progress has been made in recruiting a full complement of staff and as a result the service users receive a consistent level of care. Service users are protected by the home’s recruitment and selection procedures. The staff have a good understanding of the service users’ support needs. This is evident from the positive relationships, which have formed between the staff and service users. EVIDENCE: The manager confirmed that there is now a full complement of staff. The rota shows that staff are being deployed according to the staffing notice with the manager having supernumerary hours. The management structure now includes a deputy manager. There are separate house keeping and cooking hours. Wherever possible a cultural and gender balance is considered when developing the rota. The PIN numbers of the nursing staff are checked as part of the recruitment process and there is ongoing monitoring to ensure that these are valid. The manager is supported by a human resources department in respect of the recruitment and selection process. All relevant checks are carried including references, CRB and POVA. The organisation has a rolling programme of training in place. A training summary shows that staff have attended the core training in first aid, basic Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 16 food hygiene, fie awareness, manual handling, protection of vulnerable adults, violence and aggressions, equal opportunities and challenging behaviour including breakaway techniques. Staff also attend training in respect of training and diversity. Six of the staff have completed NVQ training. Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 17 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): Standards 37, 39 & 42 The home is being managed effectively. Service users views are sought and listened to. The home provides a safe environment for service users to live in and for staff to work in. EVIDENCE: The manager has successfully completed the fit person process to become registered. She has an appropriate nursing qualification (RMN) for the client group in the home. The manager has completed the Registered Manager’s Award, is nearly completed an Executive Management course and is planning to enrol on a Master’s Degree. The views of service users are obtained in several ways. All service users have been involved in identifying what they need in order to move on from the service. They contribute to the assessment and care planning process and at key working meetings. Service users are invited to attend regularly house meetings. The minutes show that service users make contributions and these are acted upon. Anonymous service user survey has been conducted. The Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 18 results of which are collated and published. The basis will be for the home’s development plan. A wide range of records were looked at, including fire safety, maintenance and accident reports. These records were detailed, up-to-date and accurate and confirmed that the home is being run responsibly with essential checks being made and acted upon. Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 19 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 X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 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 Mary Wollstonecraft House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 4 X X X X 3 X DS0000010325.V273677.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mary Wollstonecraft House DS0000010325.V273677.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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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