Inspection on 22/02/06 for May Road (1)

This inspection was carried out on 22nd February 2006.

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

Other inspections for this house

May Road (1) 26/06/07

May Road (1) 26/03/07

May Road (1) 30/06/06

May Road (1) 08/03/05

May Road (1) 05/10/04

May Road (1) 08/03/04

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 May Road (1) 1 May Road Chingford London E4 8NB Lead Inspector Zita McCarry Unannounced Inspection 22nd February 2006 10:30 May Road (1) DS0000036520.V285751.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 May Road (1) DS0000036520.V285751.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. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service May Road (1) Address 1 May Road Chingford London E4 8NB 020 8527 5258 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) London Borough of Waltham Forest vacant Care Home 22 Category(ies) of Learning disability (19), Learning disability over registration, with number 65 years of age (3) of places May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2005 Brief Description of the Service: The home is operated by The London Borough of Waltham Forest and is subject to the policies of the authority. It is a purpose built facility providing accommodation, care and support for 20 service users with learning disabilities. The home is arranged for unit living in four groups. The living areas are on two floors however there is no lift to access the first floor and therefore this floor would be inappropriate for anyone experiencing mobility difficulties. The home offers permanent, respite and intermittent care. It is situated in a residential location and is close to the town centre, providing easy access to all local amenities, leisure facilities and transport services. All service users occupy single rooms that are appropriately furnished and decorated. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report of an inspection undertaken in late February 2006. The inspector spoke with service users and staff and briefly to the group service manager who in addition to his own role is supporting the day to day management of the service. The inspector read a variety of documents such as care files pertaining to the care of service users and records relating to the management of staff. As the previous report had not been released to the service the inspector was unable to test requirements from that report. What the service does well: What has improved since the last inspection? What they could do better: Again the service needs to respond appropriate to disclosures when oneservice users alleges he has been assaulted by another. The service must recruit a manager to be registered with the Commission and provide sufficient management support and supervision to staff. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 6 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. May Road (1) DS0000036520.V285751.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 May Road (1) DS0000036520.V285751.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): EVIDENCE: There have been no service users admitted since the last inspection so this set of standards were not tested. May Road (1) DS0000036520.V285751.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, 9 The service users care plans continue to improve although more work must be undertaken in managing risks. EVIDENCE: The service continues to work on service users plans of care. On a care plan checked where the risk assessment clearly identified risks for one service user there was little provided in the care plan to detail the strategies to manage the risks. However the inspector tracked one care plan, which stated that only staff with training in managing challenging behaviour should provide care to a named service user. The inspector was pleased to note that on tracking this only appropriately trained staff were allocated to provided care for this service user. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 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): 12, 13, 16, 17 Service users generally enjoy the food provided. Not all service users are supported to undertake appropriate activities. EVIDENCE: The home has undertaken work with service users around menu planning and ensuring choice at meal times. One service users said he liked the food provided and another stated it was “very nice”. The home records the activities each service user to take part. There is a considerable age variation in the service users and there was evidence that the home was attempting to provide activities to cater to each groups needs. The inspector checked the records of two service users for the three weeks preceding the inspection. One of the service users had taken part in activities such as line dancing, card playing and attending gateway and the lighthouse club. The other service users file checked evidenced no recordings for any social or leisure activities, the explanation given for most of the month was that the service user was asleep. There was evidence that service users were supported to access the local community. However to accommodate escorted trips outside the home service May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 11 users left on their unit must then move to another unit to ensure staff there can provide adequate supervision. It is inadequate that service users routines and movements within their own living accommodation is compromised in this way The service has no restrictions on visiting and supports service users contact with their families. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 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): 18 ,19, 20 The service will have to improve how it manages service users medications. EVIDENCE: Personal care and support is provided to service users in the private and service users make daily choices about what clothes they are to wear. Staff confirmed that there is no set routines for service users to retire to bed or rise in the morning. The inspector checked the home’s medication. There was evidence that medications for a service user were not checked in as received. On checking the service users MAR sheet there were blank spaces where staff should have confirmed whether or not the service user had taken their medication or not. The medication cupboard in the ground floor medical room had an over abundance of medication such as over two hundred Voltarol tablets which were being held for over five months. The staff member described these as “stock”. The home needs to review its storage of medication to ensure all medication managed by the home can be audited. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 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): 22 23 The service fails to respond appropriately to allegations from service users. EVIDENCE: The inspector checked the record of complaints held in the home. There had been complaints from three service users that a fellow resident had assaulted them all on separate. A relative acting as an advocate raised one of the complaints recorded. The Commission was not notified of any of these allegations of assault. From reading the records it appears that when the first service user made the allegation he was asked if he wished to make a formal complaint. It is unreasonable for staff to be asking a vulnerable adult who makes a disclosure if he wishes to make a formal complaint. In the absence of any physical injuries staff took no action other than escort the complainant to his room. This is an inadequate response. The second complainant made a similar allegation of assault and again he was asked if he wished to make a formal complaint, the service user confirmed that he did. It was reported that an adult abuse incident form was completed but staff were unable to provide any evidence of this. There appears to have been no further action taken. It is of concern that it appears that service users should have to confirm their wish for formal action to be taken before the service adult protection processes are activated. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 14 The third allegation of one service user assaulting another was raised by a relative advocating on behalf of a service user. On this occasion and adult protection incident form was completed and forwarded to the adult protection team. The date is unclear as no copy was kept. There was evidence of adult protection involvement and a service users care plan was updated some six weeks later. On reviewing the homes incident records the inspector noted a very serious incident took place almost three months earlier. The quick actions of member of staff ensured the service user’s safety. This incident was reported to the police. However again the Commission was not notified of the serious incident and there was no evidence of adult protection involvement. The service users risk assessment noted that a strategy meeting was to be arranged but there was no evidence that action was taken. However the inspector was pleased to note that the risk assessment for the service user fully reflected the concerns highlighted in the serious incident. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 15 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 Service users live in a clean and comfortable environment. EVIDENCE: The home appeared clean and hygienic. The group living areas were comfortably decorated and distinct form one and other. However it remains a concern that there is no separate group living area for short stay service users. The service is not designed to accommodate service users with physical and or sensory disabilities. There are service users accommodated who are now over the age category for the home’s registration. The service must now apply for a variation in it’s category of registration. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 16 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 33 35 36 Staff do not have an adequate level of management support and supervision. EVIDENCE: The inspector was unable to test the homes recruitment processes as this is a function that is centralised in the organisations human resource department and all records are held there. The home has been without a registered manager for approximately two years and has failed to recruit to the post. The Commission has been advised that a group service manager is providing operational day-to-day support of the service. However on checking the rota his name is not recorded so it is unclear how much time is spent at the service. The rota also failed to reflect that the shift leader on the day of the inspection was actually leaving the service midmorning to attend training. The inspector checked the induction of a recently appointed member of the senior team and noted that there had been no induction provided in relation to fire and accidents in the home. The member of staff stated he undertook his own induction in these areas. It is the responsibility of the managing organisation to ensure all staff have been instructed on their role in the event of fire or accident in the service particularly when the employee as the shift leader would be responsible for how the service deals with such incidents. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 17 The inspector attempted to check staff files to review the effectiveness of staff supervision. It was of concern that three filing systems were presented to the inspector all from previous manager, no supervision records could be presented as evidence of the current system of support and supervision for staff. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 18 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): The service has no registered manager in post to develop or lead the service. EVIDENCE: The service continues to have no registered manager in post and this requirement is long outstanding. The service undertakes unannounced monitoring visits, and an advocate also undertakes visits to service users, there was also evidence that service users were appropriately involved in planning the menus for the service. The home does consult with carers of respite service users but there is a lack of evidence where service users feedback actually influences the provision of care. The inspector checked records pertaining to the health and safety in the service such as fire records and found these to be in order. Staff maintain records on the safe chilled storage of food. May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 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 2 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 x LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 X 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 3 x May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 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. 1 Standard YA9 Regulation 13 Requirement The registered person must ensure that the strategies for identified risks are fully reflected in service users care plans. The registered provider must ensure there are sufficient staff in duty to accommodate service users activities without infringing on the daily lives of other service users. The registered provider must ensure all service users are offered appropriate activities and supported where required to take part in leisure/social pastimes. The registered provider must there is a system by which medications in the home can be audited to ensure safe management of service users medications. The registered person must ensure that the Commission is notified of all allegations of assault. The registered provider must ensure that appropriate and prompt action is taken in all allegations of assault. DS0000036520.V285751.R01.S.doc Timescale for action 01/10/06 2 YA16 18 01/10/06 3 YA12 12 01/10/06 4 YA20 13 01/10/06 5 YA22 37 01/10/06 6 YA23 13 01/10/06 May Road (1) Version 5.1 Page 21 7 YA23 17 8 YA24 1 9 10 YA35 YA36 18 18 11 YA33 18 12 YA39 24 The registered person must ensure that full records of incidents and subsequent actions are maintained of all times. The registered person must ensure all service users living in May Road fall within the service user category of registration. The registered person must ensure all staff undertake TOPSS approved inductions. The registered provider must ensure that staff have adequate supervision and support to undertake the work they do. The registered provider must ensure that the home’s rota accurately reflects the staff on duty at any given time. The registered provider must develop an annual development plan for the service that reflects feedback from service users as well as other stakeholders. 01/10/06 01/10/06 01/10/06 01/10/06 01/10/06 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations May Road (1) DS0000036520.V285751.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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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