Inspection on 18/08/06 for Mitcham Lane

This inspection was carried out on 18th August 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 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mitcham Lane 20/06/07

Mitcham Lane 07/03/06

Mitcham Lane 10/08/05

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 Adrian Gordon Unannounced Inspection 18th August 2006 10:30 Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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 Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mitcham Lane Address 229 Mitcham Lane London SW16 6PY 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 8677 3336 020 8971 0060 Mr Clifford Steven Oakley Mr Abdelkrim Damousi Max Thembinkosi Mbangcolo Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Staffing levels are reviewed to meet the assessed needs of current and prospective service users and that waking night care is provided. No clients are to cook without supervision from staff. As agreed on 12th May 2006, service users with a Mental disorder, excluding dementia can be accommodated within the home. 7th March 2006 Date of last inspection 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 black males who have mental health needs. All residents are supported by male members of staff. Each resident has their own room and there is a communal lounge and kitchen/diner. 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. Information about the home is available in the Statement of Purpose and Service User Guide. The fees currently charged by the home range form £1100 to £1200 per week. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and completed over the course of one day. It consisted of examination of records, tour of the premises and discussion with staff on duty. The manager was unavailable but the registered provider was on site. The inspector had the opportunity to talk to all the residents. No feedback questionnaires were returned. What the service does well: What has improved since the last inspection? What they could do better: The system for monitoring resident finances must be improved to ensure residents interests are protected. A programme of redecoration for the home must be implemented to improve the environment. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 6 The registered person must ensure that staff shift patterns meet the requirements of the European Working Time Directive. Staff must receive training in core skills and have access to specialist training as required. The manager must apply to the Commission to be registered. A formal system for monitoring the quality of care in the home must be introduced and monthly monitoring visits must take place. 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 DS0000010210.V308266.R01.S.doc Version 5.2 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 Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents needs are assessed before admission to ensure the home can meet their needs. EVIDENCE: A Service User Guide is available for residents which gives a good picture of what to expect at the home. The Statement of Purpose contains all the required information, but needs updating to reflect the current staff team and manager. There have been no new admissions to the home since the last inspection. Current resident files contain copies of referral forms and assessments from when they were admitted to the home. The service is appropriate for the residents who are placed there. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good care planning information supports residents in meeting their personal goals. EVIDENCE: All resident files contained an up to date Care Plan which is reviewed and updated as required. Care Plans detail needs, goals and actions which are regularly evaluated and progress reported. A record is kept of daily events. Care Plans are hand written which sometimes makes them difficult to read. Consideration should be given to typing these up in future. Risk assessments were seen to be in place and up to date. They include anticipated risks and action plans. One risk assessment was seen to have been updated following a recent incident. Residents are supported to take risks and consequences explained, for example working with a resident to manage their money more effectively. Two residents confirmed that they are able to make Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 10 choices, for example when to get up, and when they want to go out. Resident meetings take place every month. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are able to live the lifestyles they choose. EVIDENCE: Two residents confirmed that they sometimes attend a local day centre where they can take part in activities like pool and table tennis. Another resident chooses to spend most of their time in the home. Residents are able to go to the local shops and facilities and all have a key to the front door. Two residents spoke about how their social worker visits regularly and one resident said they go and visit a relative regularly. All residents were seen to be relaxed and at home. The kitchen was a focal point where staff and residents were seen to be interacting well. Residents rights are respected, for example by staff knocking on bedroom doors, and Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 12 they are encouraged to participate in household talks. Residents have individual responsibility for their bedrooms. No issues relating to equality or diversity were raised. Weekly menus are displayed on the fridge which showed that the diet is not particularly varied. One resident said the food was ‘ok but often the same’ although they felt it had improved under the new manager. They also said that they can go out shopping for food sometimes. Another resident said the food was mostly West Indian which reflected the culture of residents. They said that they chose not to get involved in menus and these were mostly decided on by staff. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Support is in place to ensure health needs are met. EVIDENCE: Staff were observed to treat residents with respect and it was clear that residents are able to make choices and decisions about how they prefer to live. For example, one resident preferred to stay in bed late and staff were seen to respect this. Another resident had made a choice not to go to a day centre. Care plans detail health needs and a record of appointment is maintained, for example, dentist or optician. All residents are registered with a local GP. Two residents confirmed they receive regular visits from their Community Psychiatric Nurse and social worker. Access to specialist support is available through the Community Mental Health Team. Medication is stored appropriately and medication administration sheets were properly filled in. A book is used to record medication received and returned. One resident has been assessed as being able to self medicate when they are outside the home. Medication profiles should be created for each resident which detail their medication taken and any possible side effects or allergies. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The system for recording resident finances does not properly protect their interests. EVIDENCE: There have been no complaints since the last inspection. Details of the procedure are in the Service User Guide. Residents have recently been sent a memo reminding them of their right to complain. A copy of this was held on files and was seen to be signed by residents. A copy of local interagency procedures for the Protection of Vulnerable Adults (POVA) is kept in the office. Staff have not had any recent POVA training and this must be implemented. The system for monitoring and recording resident money was confusing and could potentially lead to errors. Small amounts of resident money are kept in a locked cupboard. Residents sign for any money given and records are checked at each handover. However, larger amounts of resident money are kept in a locked drawer, and it was unclear where this money came from and when it was being used. Records must accurately reflect the use of resident money, to leave a clear audit trail. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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, 25, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Parts of the home require redecoration in order to provide a suitable environment for residents to live in. EVIDENCE: The outside of the house is in keeping with other properties and is not recognisable as a care home. Inside the home was tidy and provides sufficient space for the number of residents. The kitchen/dining room was domestic in feel. Surfaces showed signs of wear and tear and the flooring was worn in places. The registered provider said that the kitchen was due to be refurbished in September. A sofa in the lounge was old and worn and the carpet leading through to the hallway was covered in stains and cigarette burns and must be replaced. Two posts in the stair rail were broken. Upstairs the décor in one bathroom was dated and the sealant had come away from the bath. A light pull switch was damaged and dirty. Another bathroom had a shower attachment which was covered in limescale. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 16 Resident bedrooms were suitable for the needs of residents. One bedroom contained a chair which was badly damaged. The registered provider said it would be replaced urgently. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 17 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, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff have good relationships with residents but lack of training opportunites and long shifts are affecting the quality of care they are able to provide. EVIDENCE: The staff team is culturally representative of residents in the home. Staff were observed to interact well with residents and were knowledgeable about individual needs. Two residents expressed concern that staff sometimes sit and watch television rather than talk to them. The rota shows that staff sometimes work very long shifts on their own. This was confirmed in staff feedback. This could present a risk to the safety and health of staff and may go against the European Working Time Directive. Staff meetings take place monthly with whoever is on shift for that day. Arrangements should be made to hold a team meeting with all members of staff present. Staff files showed that all the necessary recruitment checks are in place, including health declarations and an Enhanced Criminal Records Bureau Check. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 18 Supervision records are completed but supervisions are not happening regularly. There must be a minimum of six supervisions each year. There has been no recent core training for staff in areas such as food hygiene, POVA, health and safety and first aid. There is also no access to specialist training, such as in drug and alcohol use, which would enable staff to have a better understanding of residents needs. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Quality assurance systems must be improved in order to enable residents to have a greater say about what happens in the home. EVIDENCE: The manager was not available on the day of inspection. One resident said that things were better in the home since the manager started in October last year. An application to be registered has still not been submitted to the Commission, despite this being am requirement at the last inspection. This must be done as a matter of urgency. The registered provider is responsible for carrying out monthly monitoring visits but these have not always happened. The provider said that the result of these visits are fed back in resident meetings. There is no formal system in place for reviewing the quality of care provided at the home. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 20 Records are kept of health and safety checks on the building and these were mostly up to date and included fire tests, fridge/freezer temperatures and a gas safety certificate. The portable appliance test remains overdue. A recent incident when a member of staff was assaulted by a resident was not reported to the Commission. Systems must be put in place to ensure that all serious incidents are reported without delay. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 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 2 2 3 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4, Schedule 1 Requirement The registered person must ensure that the Statement of Purpose is updates to reflect the current staff team and manager. The registered person must ensure that the food in the home is varied, wholesome and nutritious. The registered person must ensure that all staff receive training in the Protection of Vulnerable Adults. The registered provider must ensure that systems for recording resident finances are simplified and leave a clear audit trail. Timescale for action 15/10/06 2 YA17 16(2)(i) 15/10/06 3 YA23 13(6) 15/11/06 4 YA23 12, Schedule 4(9) 15/10/06 5 YA24 YA30 23(2)(b)(d) The registered person must ensure that a programme for refurbishment and redecoration is produced which addresses all the points raised in the Environment section of this report. 15/10/06 Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 23 6 YA33 18(1)(a) 7 YA35 YA32 18(1)(c) The registered person must 15/10/06 provide evidence to the Commission that the staff shifts meet all the requirements of the European Working Directive, particularly in relation to breaks, length of night work and safety and health protection. The registered person must 15/11/06 ensure that staff receive training in core skills and have access to specialist training as required. The registered person must ensure that staff receive a minimum of six supervisions each year. The registered person must ensure that an application is submitted to the Commission for registration of the current manager. This was a requirement at the last inspection. Timescale 30/04/06. 15/10/06 8 YA36 YA32 18(2) 9 YA37 9(1) 15/10/06 10 YA39 26 The registered person must ensure that monthly monitoring visits take place, and a report is forwarded to the Commission. The registered person must ensure that a formal system is implemented to review the quality of care at the home. The registered provider must ensure that the overdue portable appliance test is carried out. The registered person must ensure that the Commission is notified of any serious incident DS0000010210.V308266.R01.S.doc 15/10/06 11 YA39 24 15/11/06 12 YA42 13(4) 15/10/06 13 YA42 37 15/10/06 Mitcham Lane Version 5.2 Page 24 at the home. 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 YA6 YA17 Good Practice Recommendations The registered person should ensure that care plans and risk assessments are typed up. The registered provider should create a medication profile for each resident that details the medication taken and any side effects or allergies. Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 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. Extracts may not be used or reproduced without the express permission of CSCI Mitcham Lane DS0000010210.V308266.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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