Inspection on 10/08/05 for Mitcham Lane

This inspection was carried out on 10th August 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 but made no statutory requirements on the home.

Other inspections for this house

Mitcham Lane 20/06/07

Mitcham Lane 18/08/06

Mitcham Lane 07/03/06

Mitcham Lane 16/02/05

Mitcham Lane 15/07/04

Mitcham Lane 16/01/04

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

CARE HOME ADULTS 18-65 Mitcham Lane 229 Mitcham Lane London SW16 6PY Lead Inspector Janet Pitt Announced 10 August 2005 09:50 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 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 Stationary 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. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mitcham Lane Address 229 Mitcham Lane London SW16 6PY Telephone number Fax number Email 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 8677 3336 020 8971 0060 Mr Clifford Steven Oakley Vacant Care home only (PC) 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) of places Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Staffing levels are reiewed to meet the assessed needs of current and prospective service users and that waking night care is provided. Date of last inspection 16th February 2005 Brief Description of the Service: 229 Mitcham Lane is situated in a residential area in Streatham, close to local bus routes. The home provides personal care for clients who have mental health needs. All clients are male and are supported by male members of staff. Each client has their own room with adequate communal facilities. The home is domestic in character and provides a homely atmosphere. There is a level garden area, accessed via patio doors from the dining area. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection commenced at 09:50am and finished at 11:55am. During the course of the inspection care documentation, policies and procedures were examined. A tour of the premises was undertaken. The inspector spoke with two clients, the provider and a member of staff. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that the Service User Guide includes details of the current regulatory authority, to enable clients and their representatives to be fully informed of who they can approach if they have any concerns. The home must demonstrate that clients views are heard and acted upon, by re-commencing monthly meetings and documenting them. Recent photographs of clients must be in place to assist with identification when required. The home must ensure that there is compliance to working time directives and document any deviation from the guidance, indicating the worker’s agreement. The provider must ensure that a suitable manager is appointed in a timely manner. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 and 5 Clients are provided with sufficient information regarding the service provided. However, the home must ensure that details of the current regulatory authority are correct. Comprehensive assessments are undertaken on clients, which identify care needs. EVIDENCE: The Statement of Purpose and Service Users Guide provide information on the service for clients. Each client was noted to have a contract in their file. Amendments have been made to the Statement of Purpose to reflect the current regulatory authority, but the Service user Guide needs to be updated to ensure that the details of the current regulatory authority are available for clients. This will ensure that clients are aware of who regulates the service and whom they can approach if they have any concerns. The contract states a twenty-eight day trial period once a client has moved into the home. This enables clients to decide whether or not the home meets their requirements. Two assessments of clients examined indicated that full assessments of clients were carried out prior to and upon admission. This clearly identified care needs and the other health professionals who were needed to help in delivering the care. The assessments also identified risks to clients and these were addressed individually with clear details for minimising risk, thus protecting clients from harm. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8 and 9 Clients are able to discuss issues with staff, but require a formal meeting, which is minuted to evidence that concerns have been acted upon. Clients are enabled to fulfil their potential within a risk assessment framework. EVIDENCE: Clients are encouraged to talk with staff to discuss any issues they have with the running of the home. The home must recommence formal monthly meetings between clients and staff, to ensure that issues are properly addressed and actioned. Clients care plans indicated that personal goals are established and assistance is given to work towards them, examples of personal goals are maintenance of personal care and developing independent living skills to enable clients to progress. Comprehensive risk assessments were in place on clients to ensure that they are able to fulfil their potential in the home and the community, but within a risk assessed framework. Examples of risks assessed were smoking, attending events in the community and cooking. Clients care plans were noted to be reviewed monthly and changes noted. Multidisciplinary reviews of care were carried out routinely and any changes to the plan of care noted. This ensures that clients receive care according to their needs. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 standard(s) 11,12, 13,14, 15 and 17 Clients are able to choose how they spend their day and support is given to enable the clients to function in the wider community. Independent living skills are promoted at the home. EVIDENCE: Four clients were at home on the day of inspection. Three people were awake and one person was still sleeping. The provider informed the inspector that only one client attended a day centre. The care plans indicated that another client was able to go shopping independently, but there were risks of absconding. Records indicated that when the client absconded, appropriate procedures were in place to ensure they returned safely to the home. One client was kind enough to make the inspector a snack. This client also enjoyed undertaking housework, and it was noted that assistance had been given to the client with laundry. One client spoken with said that they were able to maintain contact with family and friends. The provider stated that visitors to the home are monitored as the client group is vulnerable and the staff need to make sure that the clients are not influenced to alter behaviour in a negative way, e.g. non-compliance with medication. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 Page 11 The provider indicated that he had collected brochures for college courses, but none of the current clients wished to enrol at this time. The home has a set menu, but often this is deviated from as clients request alternative food. It was agreed at the time of inspection that in place of a set menu that the home would record food served, to give an indication of dietary intake. This reflects the domestic nature of the home and promotes clients independence. The provider stated that clients are encouraged to participate in cooking meals and two days a week a lady comes to the home to cook and undertake household tasks. There was sufficient space in the dining area for clients to take a meal together if they choose. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 standard(s) 18, 19 and 20 Clients’ emotional and physical needs are met by the procedures of the home. The home must ensure that a recent photograph is available of all clients to enable identification and protect clients from harm. EVIDENCE: Clients are able to leave the home when they wish and have door keys to their rooms and the front door of the house. At the time of inspection it was observed that staff were made aware when clients leave the home and where they are intending to go. Clients care plans verified that assessed physical and emotional health needs were met. There was evidence of routine dental, general practitioner and optician checks. Details of health professionals and contact with these professionals were also present. The majority of clients have social worker and psychiatric input into their care. Medications for clients were inspected and seen to be handled safely, which protects the clients from harm. Medication Administration Record (MAR) sheets were examined and there were no gaps in administration. One client was diabetic and was supported by staff to monitor their blood glucose levels, which were noted to be stable. The home must ensure that there are recent photographs of clients on file, to enable identification. One file was noted not to have a photograph. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 standard(s) 22 and 23 Policies and procedures in place at the home relating to complaints and Adult Protection ensure that clients are protected from harm and concerns are appropriately addressed. EVIDENCE: The pre inspection questionnaire indicated that there have been no complaints received in the past twelve months. The home has not had any investigation under Protection of Vulnerable Adults. Policies and procedures relating to complaints and protection of Vulnerable Adults were inspected. These were noted to give clear guidance on what should occur if there were any incidences of someone had cause to make a complaint. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28 and 30 Clients are able to personalise their rooms and are supported to develop and maintain independent living skills. EVIDENCE: Two clients gave permission for the inspector to view their rooms. The rooms had been personalised and there was adequate storage for their belongings. Clients are able to have television and audio equipment in their rooms and are encouraged to keep their rooms tidy, and given assistance if required. The provider said that one client was shortly going to have a new carpet and repairs to their chest of drawers, as the risk of smoking in the room had been minimized and the clients was now able not to damage carpeting and furniture with cigarettes. There are adequate bathing and toilet facilities for clients’ use, which are situated near to clients’ rooms. The home provides a kitchen/dining area and a lounge for clients to use. These areas provide adequate seating. One client was enjoying watching the television on the day of inspection. High dusting was noted to be done as required from the previous inspection. The home was clean and tidy on the day of inspection. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Clients are supported by appropriate numbers of staff, however the home needs to ensure that there are safe agreed working patterns. EVIDENCE: Clients are supported by an appropriate numbers of staff. One staff member continues to work a shift pattern, which does not have rest breaks of eleven hours between shifts. This must be clarified and documentary evidence held on this member of staff’s individual file, indicating that this is their preferred hours of work. This was a requirement from the previous inspection that has not been met. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 and 39 The home need to ensure that there is a permanent manager in position, this will enable clients to be confident that the home is run and managed well. EVIDENCE: The provider informed the inspector that the manager had left the home and a new manager was employed, but they too left the home. Currently the home is being supported by a manager from another home, who is experienced. The provider is also available to support the staff. The provider said that the position of manager was being advertised at the time of inspection. Clients need to be able to express their views at monthly meetings, which must be recommenced. Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 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 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 2 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mitcham Lane Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 2 2 x x x x G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 Page 18 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 1 Regulation 5 (1) (f) Requirement The registered person must ensure that the Service User Guide must contain details of the current regulatory authority. (previous timescale of 30/5/05 not met). The registered person must ensure that monthly meetings for clients are held and documented. The registered person must ensure that there is are recent photographs of clients on their files. The registered person must ensure that staffs agreement to working a particular shift pattern, which does not allow eleven hours between shifts, is docuemnted. (previous timescale of 30/5/05 not met) The registered person must ensure that a suitable manager is appointed in a timely manner. Timescale for action 30th October 2005 2. 8 12 (2) 30th October 2005 30th October 2005 30th October 2005 3. 20 Schedule 3 (2) 18 (1) (a) 4. 33 5. 37,38 and 39 8 (1) 30th December 2005 Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 Page 19 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 Good Practice Recommendations Mitcham Lane G54-G04 S10210 Mitcham Lane V230967 100805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Ground Floor 41047 Hartfield Road Wimbledon London SW19 3RG 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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