Inspection on 20/06/07 for Mitcham Lane

This inspection was carried out on 20th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mitcham Lane 18/08/06

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 Davina McLaverty Unannounced Inspection 20th June 2007 10:00 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.V342922.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.V342922.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 8677 3336 Mr Clifford Steven Oakley Mr Abdelkrim Damousi Nuncoomar Raghoo Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate up to four service users with a Mental Disorder who have a secondary diagnosis of Learning Disability. 20/03/07 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. Male members of staff support all residents. 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.V342922.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulation inspector conducted this unannounced inspection on 20th June 2007. The manager was present during the inspection and was open and welcoming. The owner was present for part of the inspection. Documentation looked at included medication records, staff training and supervision information, residents care plans and health and safety records. A tour was also taken of the premises. The manager had completed the Annual Quality Assurance Assessment (AQAA), which is a self-assessment of the service and evidence from this is used to help form some of the judgements in this report. Surveys were left for all residents to complete if they wished. Surveys were also left at the home to be given to staff and professional involved with the home. One Health and Social Care Professional Survey was received before the completion of this report. No concerns were raised. Three of the four residents were seen on the day of inspection, and the inspector spoke with two, both of whom said that they were happy at the home. What the service does well: What has improved since the last inspection? The Statement of Purpose has been amended to reflect staff changes in the home. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 6 What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Mitcham Lane DS0000010210.V342922.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.V342922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is appropriate information for people who are thinking about moving to the home. There are also suitable procedures for assessing people’s needs before they move to the home. EVIDENCE: There is a Statement of Purpose and Service User Guide for the home. The Statement of Purpose has been updated. Since the last inspection a new resident had moved in, although at the time of the inspection the resident had been readmitted back into hospital. Assessment documentation was seen on their file and also evidence of several visits to the home prior to the admission being agreed. Current resident files contain copies of referral forms and assessments from when they were admitted to the home. Reviews were seen to have taken place. The service is appropriate for the residents who are placed there. Mitcham Lane DS0000010210.V342922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the residents are identified and planned with involvement of the individual and their key worker. Residents are encouraged by staff to participate in the life of the home and to acquire new skills to enhance their lives. Residents’ choice is respected and they are supported by staff to participate in community activities. Residents are supported to take risks and maintain their independence. EVIDENCE: Two care plans was examined and seen to be satisfactorily maintained and reviewed in consultation with and signed by the resident, as well as the key worker. The care plans focussed on particular areas of need for the individual e.g. life skills, activities and communication. Care plans are regularly reviewed Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 10 and updated as required. Care Plans detail needs, goals and actions, taken by residents. A record is kept of daily events. Risk assessments were seen to be in place and up to date. They include anticipated risks and action plans. Residents are supported to take risks and consequences of the risk explained to them, for example the home is working with a resident to manage their money more effectively. Resident meetings take place every month and staff listen and respond to resident’s views. Residents are encouraged to participate in the running of their home and on the day of the inspection one resident was seen to carry out his allocated tasks. Mitcham Lane DS0000010210.V342922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home are given opportunities to take part in a wide range of activities at the home and in the community. They are supported to stay in contact with friends and families and to celebrate their culture. EVIDENCE: One resident said that they sometimes attend a local day centre. 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. Their care managers, who liaise closely with the staff team, visit residents 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. Good rapport was seen between staff and residents. Residents rights are respected, for example, by staff knocking on bedroom doors, and as already stated are encouraged to participate in household tasks. e.g. hoovering or mopping the Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 12 kitchen. Residents have individual responsibility for their bedrooms although staff will encourage residents to keep their rooms to a reasonable standard. Mail is given directly to the resident and support provided, if need be, in reading and responding to official letters. Rules on smoking, alcohol and drugs are addressed in the Statement of Purpose and Service User Guide, which all residents have received a copies of. A copy of the weekly menu submitted showed that a varied diet is offered. One resident said the food had improved since the new manager had been in post. On the day of the inspection residents choice of meal was respected and prepared by staff. They also said that they can go out shopping for food on their own or for the house shop with the proprietor or manager. Mitcham Lane DS0000010210.V342922.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. 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 this service. Staff take the health needs of the residents seriously and residents have access to a range of community healthcare facilities. Medication is stored and administered appropriately. However, omissions in the recording in the medication administration records could place residents at risk. EVIDENCE: A record is maintained of resident’s health needs and of any appointments with GP’s, dentist, opticians etc. Residents are all registered at a local GP surgery and all four residents receive regular visits from their CPN as well as their social worker. The questionnaire returned stated “ the home provides an excellent service to its clients” and “the home is a good all rounder and provides well for its clients and interacts well with the Central Mental Health Team.” Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 14 The medication cupboard was locked securely at the time of inspection. The inspector noted several entries on the Medication Administration sheet had been left blank. Administration or non-administration of all medication must be recorded and signed for. A record of staff training in respect of medication was not available at the time of the inspection. The manager stated that in house refresher training takes place, however all staff who administer medication must receive refresher training from an external source annually and a record of the training be maintained. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place with clear systems for the recording and monitoring of complaints. People feel safe and secure in the service provided at Mitcham Lane. EVIDENCE: There have been no complaints about the service in the last twelve months. Details of the complaint procedure are in the Service User Guide. One resident spoken with stated that they were happy living at the home and had no complaints Staff are trained in Safeguarding Adults and procedures for them to follow are available in the home. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. EVIDENCE: The premises are in keeping with the local community and are not identifiable as a care home. The premises are safe and comfortable with close access to local amenities. The communal areas of the home was found to be satisfactory, although the inspector held the view that re-painting of both the lounge and hallway is required as there are many areas of scuffed and marked paintwork. The manager stated that the carpet was due to be steamed clean later this week. It was stained in places. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 17 A large lounge (with television) is available with adequate seating. The manager reported that the curtains and nets were due to be changed. A large kitchen/dining room is available which leads out into the garden area. Appropriate appliances were seen in the kitchen. There are adequate bathing and toilet facilities for residents’ use, which are situated near to resident’s rooms. The manager stated that the broken toilet cover was due to be replaced, as was the light pull cord in the top bathroom, which is tied, together and grubby in appearance. The inspector was shown the new cord. The resident spoken to showed the inspector their room and said that they were happy with it. Another bedroom seen was satisfactory. On the day of the inspection the home was found to be generally clean and tidy. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have good relationships with residents, the staff team are able to support residents in meeting their needs. Supervision and regular staff meetings take place. EVIDENCE: Since the last inspection no new staff have been employed and as staff files were examined at the previous inspection they were not examined at this inspection. The staff member spoken with was clear as regards his role and responsibilities. He stated that he enjoyed working in the homes as he found it homely and one could get to know the residents and their needs more quickly than in a large home. 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. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 19 Staff meetings are talking place, as was supervision. External refresher training had taken place recently with the exception of medication, which the manager and proprietor said had been carried out “ in house”. The manager also stated that in house training is offered by himself on areas such as drug and alcohol use, which enables staff to have a better understanding of residents needs. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and safety systems are in place to ensure the safety and welfare of the residents. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. Service satisfaction questionnaires will help to monitor the quality of the service provided to residents and contribute towards the development of the service. EVIDENCE: Since the last inspection the manager’s application has been approved by the Commission for Social Care. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 21 The registered provider is responsible for carrying out monthly monitoring visits but these have not always happened. The proprietor said that the result of these visits are fed back in resident meetings either by himself or the manager. A quality assurance system is being put in place and the inspector was informed that questionnaires have been sent out to residents and stakeholders. Records are kept of health and safety checks on the building and these were up to date and included fire tests, fridge/freezer temperatures and a gas safety certificate. Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 23 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 2 3 4 Standard YA20 YA20 YA24 YA43 Regulation 13(2) 13(2) 23(2) (d) 26 Requirement Medication administration records must be fully completed for all residents. Refresher medication training must take place annually The hallway and lounge areas require decorating. Copies of the reports from the provider’s monthly visits to the home must be available for inspection. Timescale for action 30/06/07 30/09/07 30/12/07 01/09/07 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 Mitcham Lane DS0000010210.V342922.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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